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Interventional Procedures for
Spine Pain Spine Pain Moises lustgarten, md
Medical director
Center for Pain management at Baptist Hospital
Financial Relationship disclosure
! Nothing to disclose
Learning objectives
! Be able to identify those patients most likely to benefit from interventional modalities
! Understand the differences between the various
procedures used to diagnose and treat LBP
! Recognize limitations to each procedure
! Develop strategies to maximize treatment outcomes
Epidemiology
! Major medical problem: > 5 million people affected
! Major economic problem: >$25 billion per year
! FBSS:
! 200,000 patients undergo back surgery every year
! 20-40% persistent pain or recurrent pain:
! Erroneous diagnosis Radiculitis
! Column instability Recurrent herniation
! Erroneous location Arachoiditis
! Epidural fibrosis
Lumbar Spine Anatomy
! Bone / Vertebrae
! Disc
! Annulus
! Nucleus Pulposus
! Muscles / Ligaments
! Spinal Nerve Roots
Lumbar Spine Anatomy
cross-section
Lumbar Spine Anatomy
! Facet joint
! Zygopophyseal joint
! Synovial
LBP
! Sacroiliac Joint
! Tight, Synovial
! Ligaments
! “SI Dysfunction”
Interventional Pain Procedures
! Interventional modalities to identify and interrupt pain pathways
! Nerve stimulation
! Nerve ablation
! Dorsal column stimulation
! Selective epidural injection
! Selective nerve root isolation
! Percutaneous decompression
Common Procedures
! Selective nerve root blocks
! Joint injections
! Ganglion injections
! Local anesthetic infusions
! Implantable intrathecal pumps
! Spinal Cord Stimulation
! Radiofrequency Neurolysis
Common Procedures Center for Pain Management of South Florida
! Epidural steroid
injections
! Permanent epidurals
! Facet Joint Injections
! Epidural blood patch
! Trigger point injections
Interventional Failures
! While interventional treatments may provide
excellent relief there is a subset of patients
that will require pharmacological
management
Trigger Point Injections
! Most basic intervention known to help with
myofascial pain syndrome
! Different types of medications and/or
combination of different pharmacologic
agents: local anesthetics +/- steroids +/-
opioids, botulinum toxin
Epidural Steroid Injection
! The Epidural injection or catheter is a versatile technique than can be utilized for types of acute or chronic pain.
! They are most well known for labor and delivery
! They can also be utilized to deposit anti- inflammatory medication around the spinal nerves
Epidural Steroid Injection
! Epidur al steroid injections are used for a number of chronic pain states.
! T h e y a r e m o s t e f f e c t i v e f o r b u l g i n g o r h e r n i a t e d d i s k s , a n d n e r v e r o o t irritation
Anatomy
! Contains fatty tissue, venous plexus, lymphatics and dural projections of spinal nerve roots
Epidural Injection
Epidural Steroid Injection
Thoracic epidural Injection
Cervical Epidural Injection
Selective Nerve Root Block
Selective Nerve Root Block
Facet Joint blockade
! Local anesthetic blockade of the joint or innervating nerves helps make the diagnosis
! Intrarticular or periarticular steroid injections may provide prolonged relief
! Cryo or radiofrequncy dennervation of the medial branch nerves is an option if local anesthetic blockade gives good but temporary relief
Facet JOINT ANATOMY
Facet Block
Facet Block
Cervical Facet Block
Radiofrequency Denervation
Lumbar Facet joints
Radiofrequency Denervation
Cervical Facet Joints
Sacroiliac Joint Injection
Sacroiliac Joint Injection
Lumbar Discography
Discography
INTRADISKAL
PROCEDURES
! PERCUTANEOUS DISK DECOMPRESSION:
LASER, NUCLEOPLASTY
! THERMAL ANNULAR DISRUPTIONS (IDET)
Dorsal Column Stimulation or
Spinal Cord Stimulation
Electrodes placed
w i t h i n t h e
e p i d u r a l s p a c e
can alleviate pain
in a wide variety of
locations.
They substitute pain
w i t h a m o r e
p l e a s a n t
vibration.
Spinal Cord Stimulation
Intrathecal Pumps
! Proximal end is in the CSF ! Allows for smaller doses
! Catheter is Tunneled under the Skin
! Distal ends attached to the Pump, which is subcutaneous
! No external pump
! Rescues are not given via the Pump, usually, oral
! Refilled approximately every 4-6 weeks
Intrathecal Pumps
! New advances in pump technology have led
to design applications which have resulted
in smaller pump sizes
! However pump capacity has increased
! Increasing patient comfort and allowing
for less frequent need for refilling in
certain cases
Conclusion
! Proper diagnoses is required for appropriate intervention to
provide optimal relief.
! From simple trigger point injections to a highly complex
spinal cord stimulation are very effective if chosen properly
! Low back pain treatment is multifocal, can be managed, but
very difficult to treat and cure.
References
! Interventional Therapies for Chronic Low Back Pain: A Focused Review (Efficacy and Outcomes), Vikram B. Patel, Ronald Wasserman and Farnad Imani.
Anesth Pain Med. 2015 Aug; 5(4): e29716
An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations, Laxmaiah Manchikanti et al.
Pain Physician 2013, 16:S49-S283
Questions
! Moises Lustgarten, MD
! E-mail:
! Center for Pain Management at Baptist Hospital
! 305 279-3223
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