The following is a transcript of the latest podcast that can be found at the Headache 360 podcast on Apple or wherever you get your podcasts. The video can be found on our website at headachesurgery.com or on our YouTube channel for the Migraine Surgery Specialty Center. Migraine Surgery Specialty Center Youtube Channel.
The following presentation is by Dr. Adam Lowenstein, MD who is a plastic surgeon Board Certified by the American Board of Plastic Surgery, who specializes in nerve decompression surgery for chronic headaches and migraines.
Announcer: Welcome to the Headache 360 Podcast, a place to listen and learn about the diagnosis and treatment of chronic headache and migraine pain because information can be the best medicine.
Dr. Lowenstein: Hey, for those of you listening on the Headache 360 podcast, please know that this video can be found on YouTube search for Migraine Surgery Specialty center, or you can look at it on our website, headache surgery.com. Under the media tab, Scott got some kind of, I don’t want to say gory, but it’s intraoperative photography has a little blood and whatnot, so if that’s not your thing, please feel free to listen. If you do need some visual aspects of this podcast, please check the videos out on our website or YouTube. Thanks.
Hey, it is Dr. Lowenstein and if you’re listening to this by podcast, welcome to the Headache 360 podcast. And if you’re watching by video, I hope you find this well both ways. I hope you find it very, very informative. We have something really special here. We’re following a patient from the preoperative aspect of her surgery. So you’re going to see her in the morning before her surgery and what that whole process is like. And then through the surgery she had several issues as far as nerve compression in the occipital area while we were doing her headache surgery. And so you can see lots of different videos. So it was really only for people who have good strong stomachs to watch on the video. Otherwise, strongly recommend you go head over to wherever you get your podcasts and listen to this on the Headache 360 podcast.
But we have this poor patient had a lot of problems, blood vessels, fascial impingement of her nerve, lymph nodes, and you get to see all of this in video clips. And as well, the next day you get to see her come in and she’s going to kind of describe her experience going into surgery and then the following day, and I hope you find this really helpful for expectations and kind understanding of what it’s like to have migraine surgery or headache surgery or nerve decompression surgery, whatever you want to call it because all the same thing. And I hope this is really helpful for you. Great.
Alright. Hi, this is Dr. Lowenstein and we are here today before we’re doing surgery and we’re going to talk about how we’ve gotten here, what we’re planning on and whatnot. So I’m going to say your name and how’d you get here?
Courtney: I’m Courtney. I’ve been dealing with migraines since I was in my early twenties, my mid forties now. But you look in the early Yes, with all my makeup off that’s totally different. But yeah, so I’ve dealt with chronic migraines since, like I said, in my early twenties. I’ve done every type of medications you can think of, both herbal prescribed, I’ve seen numerous doctors. Nothing really works at this point. I just want something to more, as I’ve gotten older, I don’t want to be taking all the different types of medications, so I’d rather just find something that helps that at this point in my life. So all the Botox and all those different things, it’s not something I really want to be doing anymore.
Dr. Lowenstein: So how often are you having headaches now?
Now I’ve been having ’em probably what, daily? So just for, yeah, daily. I do have, there was a stint there when I transitioned off all of my migraine medication to just do all the herbal remedies. I didn’t have ’em for probably a good four months. Might’ve had a headache every once in a while, but then once your body gets used to all those things again, the migraines come back and they come back in full force. So that’s actually where Andreas was like, oh, you should meet Dr. Lowenstein, he specializes in migraines. I was like, okay, let’s see what happens.
Dr. Lowenstein: Alright, and so can you talk about what happened when, so you came into the office, we had a consultation, correct? Can you talk a little bit about your experience with the consultation?
Courtney: So I essentially came in, we spoke about the nerve block, how it would work or could work and if it did, obviously it wasn’t, it was just a bandaid. It was just to see if the surgery was right for us. Diagnostic, not therapeutic for me. Correct. And as soon as it took, I don’t know, I think our conversation took longer than the actual nerve block. My nerve block took maybe a minute and then it worked. It was great right away. When you say it worked, what does that mean? I had nothing. It was essentially there was no pain, no nothing. It was just I guess how normal people are without headaches. Now with that being said, once the nerve block were off, I was down for three days and that can happen, does not often happen. But because the nerve got irritated by the needle and what I put in there, a lot of times I was actually talking to somebody yesterday and she gets nerve blocks with the same stuff and she has no headaches for three weeks after that.
Dr. Lowenstein: So variability. You have the short end of that stick where you had a really bad reaction to the irritation of the actual nerve block. Some people that nerve block allows the pain loop to be stopped and then after that the muscles around the nerve because the pain loop is stopped, relax, and then you can have some prolonged reaction. What we usually expect is one to three hours of good and then the headache comes back like it normally does, but sometimes it’s better, sometimes it’s worse. I’m sorry for you It was bad.
Courtney: It was almost a week though. I think it lasted for about a week. It worked. It worked. It was amazing. Until it wasn’t. Until it wasn’t.
Dr. Lowenstein: So today, and this was occipital, correct? Because we have some people have surgery in the front. We’re going to do surgery in the back. And so I’m going to show you what we do as far as the whole pre-op situation. You just got here a little bit ago, right? And you have your IV in, correct? Right. Okay. So you saw Jody, she put your IV in. Are you nervous?
Courtney: Yeah, of course I’m nervous. Okay, good. I mean not good, but that’s normal. But I think I remember you saying that, that I can be nervous. You’re not nervous, right?
Dr. Lowenstein: I’m not nervous. I’m excited because it’s my favorite thing to do. So we’re good. A really nice day, it’s great for me. Perfect. But yeah, you want in general, as a patient, you’re supposed to be nervous. When I go in for surgery, I’m nervous just because it’s a control issue honestly for me.
But as you want to make sure generally speaking that you’re doctor’s not nervous. Perfect. Alright, so let’s do the next step, which is fun part shaving your head. Okay. But we don’t shave your head. What we’re going to do is I’m going to shave a strip here that, so when I’m operating, there’s no hair in the operating field. Okay? So to do that, I’m going to have you loop your legs over towards your husband there. Okay? And you have been kind enough to put your hair up. That’s great. And your hair is going generally vertical, so that’s great. We don’t want, if your hair is coming from one side to another and we shave it, then you also get a haircut from one side. But we want to make sure it’s pretty vertical. Let’s just make sure that, let’s take that out for me. Okay. And I’m just going to have you hold your hair. I do want to make sure that it is kind of as back to front as possible. I put this in pretty good thinking. I wouldn’t have to take it out. Well, they’re going to take it out later anyway. They’re going to braid your hair. Okay. So I just want to make sure that I want to maximize your hair. Alright, so we’ve got some interesting stuff here. You have a stork bite, you know what that is? Yeah, I do. I think we talked about this last time. You have it as well? Yes, I have it as well. And afterwards we’ll kind of bring this up and show everybody. But that is a capillary affirmation back here that we who have this problem, including myself, a lot of patients have that. So alright, this is going to be a terrible sound right for somebody who has long hair, but I’m really excited and it is working it.
All right, so come tight for me. There we go. That was the worst part. No, the worst part is when I tell you, so in my prior career was a cosmetologist. I’ll grade you on this later there. All right, fair enough. I don’t usually show patients what I take by the takeout, but all these people on the video might see this and my hair, it looks traumatic, but you’re not even going to be able to tell. I was going to say my hair’s really curly so I brushed it out and so it’s going to look crazy. Anyway, no, it looks like my wife’s, yeah, your wife. Yeah, she has really curly hair too, so you know what it looks like when it’s brushed out. A really scary, weird thing is my hair used to be not quite as long as yours, but not far off. And when I brushed it out, it did that too, but that was a long time ago. Okay, so I’m going to bring this over here.
So that is what hair looks like after shaving and what it’ll still look like later. And then we go up here and we see that, so that’s the strip that we’re going to operate in. And I’m going to make an incision that goes from here just down to here, all in the hairline. And you can kind of see it’s all red now because of the razor, but you can kind of see these little spots here. That’s the capillary malformation, which I’ll show you too. Alright, so go back here
Dr. Lowenstein:
So this is your occipital protuberance. You can be up. So upright is better. Head up. There you go. Okay, so that’s your occipital protuberance in the midline. That’s about the base of your hair line. So I’m going to just make a mark here and that’s where our incision is going to be. And then I’m going to get my ruler out and we are going to go three centimeters down from the occipital pitance, make a little line there and then one and a half centimeters on each side. And is that about where the pain hurts? Is it different?
Courthney: Yeah, that’s it. And there, yes. Right.
Dr. Lowenstein: So that’s where the nerves are. And then we’re also going to address the lesser occipital nerves, which are just because I think while we’re in there, that also can be an issue as far as pain over here. And so that goes again, look straight ahead. Okay, so we’re going to go from where the external auditory ATU is. So basically the hole that goes into your ear. And then we’re going to go down about five and a half centimeters from there. And then we’re going to go across6.3 centimeters, six and a half centimeters, which is there. And then over here the same.
And those are where theLesser occipital nerves are. So we make a small incision, which actually corresponds really nicely. Again, let’s try to pull This up here. Have my hair tied, just this little one. I’ll take this.
So right there is where the lesser occipital nerve comes out. So I’m going to make a small incision. I’m going to make a mark here where I expect the nerve to be and make a small incision right here. And I’ll do the same on this side, but I’ll also show you thatThis corresponds to the back of what’s called the sternocleidomastioid muscle, which is this muscle right here. And you can kind of turn and see that that muscle is there. You can also kind of, sometimes it’s less so to see it on this side, but this is the muscle that goes from here down to the clavicle and that’s where the nerve comes from. It’s interesting that whenever we mark with those dimensions, it always just ends up at that level of the posterior sternal cla mastoid. So small incisions here and there, and we’re going to cut those nerves and bury the nerves into muscle because they innervate only a very small area right here and you’re not going to even notice that those are gone. But when they’re irritated, they can cause some pretty significant headaches. And then here we’re going to make that, oh, this is where the incision is. We’re going to make it probably a little smaller than this probably from here to about there we have a nerve here and a nerve here. That’s where the greater occipital nerves are. And I’m going to go down and then over and then down to find the nerve and then free it up and down as is discussed significantly in a lot of my other videos and stuff. So That is what I Need to do. I’m just going to reinforce these incisions. We’re also going to obviously clean your head and neck and surgery and we want to not have my marks go away and then you can flip over back normally. And that’s that. What other questions do you have? I don’t think I really have any right now. Okay, Andreas, any questions? Lungs to surgery, surgery’s going to take me probably about two and a half to three hours. That’s going to take me two and a half to three hours. However, we’re going to go back, you’re going to go to sleep, then we have to position you. Positioning takes about 45 minutes because we’re going to put you face down. We got to pad your face adequately. So the tube that’s helping you breathe during surgery is not under any tension, all that kind of stuff. And there are some things between here and here that we don’t want to put too much pressure on.
So we’re going to make sure that you’re padded adequately. And so afterwards, you’re not having any issues with pressure sores or anything like that. That whole thing takes about 45 minutes. Now after surgery, I’ll tell you, you are going to be in this position for a while with this foam and the foam is going to, has an area right here to allow the tube to come out and all that kind of stuff. Being on your face like that for about a couple hours is when you come out, you’re going to look like you have just had your lips done. Perfect, okay? That’s going to go away over the course of the rest of the day. So for better or for worse, you’ll see what it’s like to have a bad aesthetic plastic surgery. Perfect. Yeah, but that’ll go away,
You’ll look normal. That is exactly right. But it’s often I kind of want to take a picture and say, see, don’t do this. This is what Yeah, but we don’t take those pictures. Good. Let’s not do that. All right. And if there’s an opportunity in the case, I’ll take some photos. The problem, I’d love to be able to video the whole thing, but we are in a small area and the nerves are in a tunnel that go up into the scalp and kind of down. So taking a video of that is really, really, really hard actually taking a picture and managing the focus because the difference in focus of four millimeters changes the depth of field and you can see something that’s pertinent and you cannot see something that’s pertinent. So you do our best and then we’ll kind of dub in what we saw.
And then I’m not going to subject her to videos today after surgery because she’s going to be out of it and I don’t think that’s fair. But we’ll maybe take some videos tomorrow morning when you come in, you can tell me how you’re feeling, what your experience of today was, and then we’ll see you again next week and we’ll see you again the week after that. We’re going to close with staples back here because staples evert the tissue and that allows hair to grow through the incision much better. Another way to do it is to use sutures, but because the suture goes in and out on the sides of the incision tends to strangulate some of the hair follicles. And the advantage of sutures is that you don’t have to have ’em taken out. But the disadvantage is that it tends to leave a wider area where you don’t grow hair since you’re local, which is a minority of my patients, but we’re lucky then when I see in two weeks, we’ll take those staples out and it’ll look a little Frankenstein between now and then when you look at it. But your hair will be down over it and you can’t see that spot anyway. But you’ll manage and I’ll take the pictures and yeah, we’ll take it from there. Okay. Alright. Perfect. Thank you. You bet.
And so after discussion of difficulties with video here, we decided to try the iPhone in surgery and it worked out great. Here you go with a bunch of video and discussion of Courtney’s operation.
Shelly is prepping her head and we’re going to get everything obviously super clean with Betadine, kills all the bacteria and make a new operative field that is completely stove.
So here you see as we first make our incision and we do some dissection over towards the lateral aspect of the neck to expose the area where we’re going to go down into the muscles to find the nerve. So here now we’ve opened the muscle in the fascia underneath and you can see the nerve coming from the bottom right towards the top left. It’s actually coming more from the midline or central neck and going up to the lateral portion of the neck where it provides a sensation or feeling to the scalp on that side. But you can see kind of flat, not a whole lot of vasculature in the nerve and looks compressed from the surrounding structures.
You saw a second ago, the initial when we found the nerve, how it was splayed out and very, very compressed. Now it’s kind of rounder looks better, but here you can see this is an artery that is wrapping around the nerve and causing compression on the nerve and we are going to take that away so it’s not irritating the nerve anymore.
All right, so now we have the nerve that it’s decompressed all the way down through the stabilizing muscles of the neck. This is actually a branch which is the third occipital nerve that we’re going to bury this into muscle. This is the greater occipital nerve. And then as we go up here, you can see that it has, we can show you this several branches that have been all dissected free up into the subcutaneous tissue here. So this is all nice soft fatty tissue below the skin. All of the crossing blood vessels have been cauterized and removed the crossing bands of muscle as well as the compressing muscle. If you remember the first picture that we showed showed this really splayed and compressed. Now you can see here, hopefully you can see this in the video, but there’s little blood vessels that are coming through here that’s a healthy looking nerve. So we’ve finished the compression, we’re going to move on to the other side.
Now here we’ve moved on to the left side, which is where Courtney has even more headache pain than on the right. And as we have opened the fascia here, we can see the nerve and it’s hard to see on this picture, but close up on the left side of the nerve, you can see that there’s a little blood vessel there. That is the first thing that we’re going to have to address after exposing the rest of the nerve and looking at if there are any fascial bands that are flattening it or crossing it.
Alright, so right now here we have the nerve and you can see these bands of tissue, I don’t know if you can see them there. The blood vessel here has been divided but still has to be dissected away from the nerve. So this whole area is just a disaster for headaches. Here you’ve got these crossing bands that are compressing things and the adjacent blood vessel. And if you can stay right there, I’ll show you here what happens, just try to get under these bands and cut them. And then I’m going to get under here. You see all of these compressive fibers, we’re going to get rid of those two here too.
That’s that blood vessel.
We’ll control that with a little cautery right there. Okay,
Blood vessels gone and those bands are gone and you can already see it. We still have compression up here, but you can already see how now the nerve is rounder, plumper and healthier. And you can see there’s little
Some branches up here. We’re going to dissect up there and dissect this out and decompress this out even further. But right now you can see that is a much happier nerve than we saw just moments ago. So here we have the nerve, which we’ve decompressed, we talked about that. And this is heading up into the subhan tissue of the scalp. This here is a big lymph node pushing right on the nerve, so we’re going to remove that lymph node, but again, we’ve seen now blood vessels compressing the nerve pieces of bands of tissue fascia compressing the nerve and now this lymph node also bothering the nerve. So she has a whole lot of reasons to have headaches and we’re just going to keep going and get rid of each of them as we find them. Alright, so poor Courtney here. Her left side was the bigger problem.
So now we’ve seen a blood vessel over here. We’ve seen crossing bands that just, and the big lymph node. Now right here, I don’t know if you can appreciate this, but this is a big blood vessel that is coming and wrapping and going actually through the nerve. So I’m not sure you can see that. But there are branches of the nerve that go under the blood vessel here, branches that go over the blood vessel here. So we need to get control of this blood vessel, which is just every time it pulses with her heart rate is pushing more and more on the nerve. So yet another reason that this nerve is really, really irritated.
So here we have the nerve. All of this is a huge blood vessel that actually tracked right up to the very, very tip. I don’t know if you can see this down in this deep, deep hole, but this is all subcutaneous tissue. So we’re in the fat just below the scalp here, all of this. And so we have all of these nerves that are dissected free into the scalp. There’s a branch, there’s a branch, there’s a branch, and this is the main trunk which goes way up high. And there’s a blood vessel that tracked a big, big artery right with it. So I had to go way, way deep here to try and control that artery. And then there’s actually even another branch right here and you can kind of see this is all dark. This is all kind of scorched from having to get these just nest of blood vessels away from the nerve.
But now here you can see that the nerve is very free and down here now we’re, it’s still kind of entrapped here, so we’re going to go and decompress it down towards the neck now. So now we’ve got a big trough here where comes through the muscles. So all decompressed here and then as you come up here, goes up into there and all decompressed all the way up here into the scalp. And I want you to come over here and just kind look here. You can see that my scissors are right here below the south. I can feel them at the skin here. So I know that we’ve got a good release all the way through the scalp. Alright, thanks.
Alright, so we are here with Courtney on the morning after surgery, it’s nine o’clock. How you doing?
Courtney: Good, good.
Dr. Lowensten: Just like this, the best morning of your life? You want to feel like this every morning? How was your night?
Courtney: It was okay. It wasn’t too bad. I don’t think it was that bad of a night. No, you woke up once around two maybe. I think I woke up more than that. Yeah, I think, I mean pain wise it’s just surgery. Pain wise, I don’t have a migraine. Okay. I think pain medication wise, I’ve only taken what, four, maybe three. Both. Three or four. Three or four pain medication in total since I left out of here.
Dr. Lowenstein: Okay, three. I mean, and you’re on Norco, right? Okay. So what I’m going to tell you is that I want you off the Norco as soon as possible-its just narcotics in general are terrible for you and will cause constipation and wonkiness. There’s a whole world of problems with ’em. So as soon as you can get off them, the better you can take Tylenol. You can’t take Tylenol and Norco at the same time because Norco, Percocet, all those things have Tylenol in them. And so you don’t want to overdose on Tylenol. That’s a horrible liver failure failure. So you want to space out the narcotics and the Tylenol by at least four hours. I expect you to be on the narcotics probably tonight, maybe tomorrow. But I’d like you to start tapering things starting tomorrow. I’d love to have you on Tylenol alone. Today’s Friday. So today’s Friday.
And so let’s get you hopefully on just Tylenol by the end of the weekend.
Courtney: Sure. Okay.
Dr. Lowenstein: You got these stockings on that are compression stockings. I want them down to your toes and I want them on through the weekend. You can take them off on Sunday down over my toes like they are right now. Are they? Yeah. Yes. Here. Just like that. Those are perfect. Yeah, some people wear them up higher and that can cause swelling of your toes and that’s to the compression from there all the way up. And in order to prevent blood clots and things like that, we want you up and around but not doing too much, right? So no, no exertion, right? No unpack in boxes. Yeah. Hi Shelly. Hi. Anyone come in and say hi here. Come over here Shelly. Hi. One of our nurses. So yeah, no exertion. I don’t want you near pets. Andreas excluded and Ali shouldn’t get too close either.
Everything looks good back here and we’ll bring you around here in a second. And so you can shower, can wash your hair. You need to be very gentle back here. Okay? I can actually wash my hair. You can wash your hair. Water can come down over the incision. You just can’t submerge in stagnant water. So no pool, no whatsoever. All right, no diving in a, yeah, right? So no hot tub. No hot tub because it’s big. You don’t want steam up there, but it’s okay for water to run down over the incisions. Okay? Okay. And what else do I have to type? I’m glad you don’t have any headache paint. That’s awesome.
We haven’t gone over the findings yet, although a lot of you all probably already know the findings. I’ve got a whole bunch of video stuff, okay? And we are, I’m going to show that to shortly offline here. But particularly your left, your right nerve didn’t look great, but it was flattened and compressed and we fixed that. Your left nerve really had, every problem that you can have was flattened by fascia. It had a blood vessel with it in the low part. The deeper tissue was compressing it as it went up. You had a lymph node pushing on it. Then you had one of the biggest arteries I’ve ever seen that actually pierced through the nerve, wrapped around it and then traveled up with the nerve. So you had all of the trifecta of had fun problems. It was, yeah, I had fun. But it’s really nice to get a really, you go in there, see what was wrong and be able to fix it.
So I’m very optimistic for your outcome, which is typically where my migraines work too, is mostly on my left side. Yeah, that’s great. And that makes sense. What we expect now, we expect you to be numb. The nerves are annoyed that I was hanging out with them yesterday. And that’s going to, what happens from now on is extraordinarily variable. Okay? This migraine, excuse me, this surgery pain should get better over the next week. Hopefully a couple of days the migraine pain may stay gone, it may come back a little bit, it may come back with a vengeance. You may have good days and bad days over the next six months and we will often see shooting pains, which are paresthesias as the nerve wakes up. And that can happen again starting next week. And it can also not happen and it can start in three months and it can, everything, the way nerves recover is extraordinarily variable.
So anybody who at this point tells you exactly what’s going to happen is full of it. Okay? But what we do know is that you’ve got a better than 90% chance of being better than you were two days ago before the surgery. And I’m optimistic that you’re just going to do very well. But if you start to get headaches, it’s not a panic situation, it’s an expectations that you should expect that. Okay? Does that make sense? If you expect the worst and we do better than that, then that’s great. But I want patients to expect good days and bad days over the next three to six months. Sometimes even longer than six months, but usually six months. Okay? Any questions that you guys have? No, not really. Start with the Tylenol as soon as you can handle it. Yeah, absolutely. Okay. And let’s here, I’ll just go back here
Just to show everybody what it looks like here. So these are the incisions for the lesser occipital nerve. And back here we have things stapled. It looks very Frankenstein and looks terrible to you all I’m sure, but you can also kind of see how the skin is raised and Ted here, which improves the hair growth through it. So an ugly situation now should lead to a much improved scar and hair growth through that area. Later we’ll get these staples out in 10 to 14 days. Underneath these tapes here and there, there’s an incision with just absorbable sutures. So this tape will fall off by itself in the next week or two and underneath there those incisions will just heal by themselves. They don’t need anything done
And, alright, so I’m going to go get my, I had to get at home last night, I had to do a little iMovie stuff to try and get everything in consecutive order and whatnot. So I’ll go get that stuff and review all that stuff with you. Okay? Sounds good. Alright, thank you very much for helping me with all of this and absolutely, you’re welcome. People know what’s going on. Alright.
Okay. And thanks again to Courtney for letting us all learn from her course here. I do want to clarify what we expect is a variable experience for three to six months after surgery. Some people have no headaches, some people have intermittent headaches. But as things improve at three to six months, we do expect you to have a significant improvement, if not complete elimination of your headaches after the recovery, the recovery period being the variable, the result of the surgery is much less variable with over 90% of people getting significantly better and about half of those people getting a completely headache-free. So again, thanks to Courtney and if you all have any questions or want to discuss your particular case, please give us a call. Nine six nine nine zero zero four is the phone number of our center and my staff will be happy to set up a consultation and we can talk further. Alright, thanks again for listening and thanks again to Courtney. Take care.
Hey everybody, this is Dr. Lowenstein once again and I have two last things to ask of you. Firstly, the thing you can do for fellow headache sufferers is to please remember to subscribe and rate our podcast. The more ratings and subscriptions that we get, the more visibility that we’ll get and the more listeners will be able to find us. And the more help and information we’ll be able to provide the huge population of people who suffer from headache pain. Secondly, please remember that the treatment of headaches of all types is very individualized. The purpose of this podcast is not to give medical advice. So please use the information here on this podcast and elsewhere that you hear on the internet to broaden your knowledge. But consult with your physician before acting on any information that you hear on podcasts or see on YouTube or read anywhere on the internet. I as a physician, don’t necessarily endorse the opinions or practices of my guests. And if you have particular questions that you’d like to consult with me directly about, please call our Headache Surgery Center. Our phone number is (805) 969-9004 or you can email us at info@headachesurgery.myfastpic.com and my staff will set up a consultation and we can discuss your specific case over the phone or in person. Our website is filled with information as well. And that is headache surgery.com. Thanks and best wishes from all of us here at the Headache 360 Podcast.
