interventional treatment chronic pain - zol · anamnesis • pain begins in the neck radiates...

Interventional treatment chronic pain

ZOL 24/3/16

Koen Van Boxem, MD, PhD, FIPP

Sint-Jozefkliniek, Bornem en Willebroek

Content

I. Interventions

II. Spinal pain

• Lumbosacral radicular pain

• Lumbar facet pain

III. Non- Spinal pain

• Trigeminal neuralgia

• Cervicogenic headache

• Occipital neuralgia

Outline

• When ? – conventional treatment failed

– pharmacologic untolerable side effects

– balance possible benefits against potential complications

Outline

• When ? – conventional treatment failed

– pharmacologic untolerable side effects

– balance possible benefits against potential complications

• Interventional options ? 1. Injection therapy

2. (Pulsed) radiofrequency treatment

3. Neurostimulation

1. Injection therapy

Targets nerve(s) involved in pain condition

– local anesthetic

» immediate pain reduction

» potential anti-inflammatory action

– corticosteroid

» anti-inflammatory action

– biological agents e.g. botulism toxin, anti-NGF, anti-TNF

» Value ?

2. Radiofrequency treatment

• High frequency electrical current adjacent to a nerve

– change in structure changed pain conduction

Chronic radicular pain - PRF

After positive diagnostic block :

Pulsed RadioFrequency (PRF) treatment adjacent to DRG:

Geurts, Lancet 2003

Van Boxem et al. In press

Burst of RF No RF



Continuous radiofrequency

Pulsed radiofrequency

Pulsed radiofrequency treatment




Continuous administration of

high frequency electrical current

Production of heat

Nerve damage


Sluijter et al. The Pain Clinic 1998; 11 (2): 109-117

Pulsed radiofrequency treatment




Continuous administration of

high frequency electrical current

Production of heat

Nerve damage


Short electrical pulses with higher

voltage followed by a silent period:

heat is washed

out

Less nerve damage

Sluijter et al. The Pain Clinic 1998; 11 (2): 109-117

3. Neurostimulation

From Smits H. et al (2012)

Mechanism SCS for Neuropathic Pain

Summary SCS NeuP

Linderoth & Meyerson, Anesthesiology 2010

RVM & LC

Content

I. Interventions

II. Spinal pain

• pathofysiology

Ontstaan rugpijn

Wervel : • Geniaal qua architectuur

• 200 miljoen jaar evolutie tot mens

Maar … we zijn

rechtop gaan lopen :

• Evolutie : grote stap voorwaarts

• Maar voor rug … een vergissing

Tussenwervelschijf

Facetgewrichten

1.Discus smaller 2.Verschuiving wervel

facetarthrose

3.Vernauwing uitgang

zenuwwortel

Content

I. Interventions

II. Spinal pain


• Radiculaire pijn: – Ontstekingsreactie zenuwwortel (hernia)

– Lage rug : Lumbo-sacraal

– Uitstralingspijn bv. L5 of S1

• Radiculaire pijn: – Ontstekingsreactie zenuwwortel (hernia)

– Lage rug : Lumbo-sacraal

– Uitstralingspijn bv. L5 of S1

• Frequent:

1/20 van de mensen ouder dan 30 jaar

→ Meest voorkomende vorm van zenuwpijn

• Lage levenskwaliteit

Doth 2010, Bala 2011

• Spontaan verloop : 75 % herstel 3 maanden maar …

– resterende 25 % : ongunstig, vrouwen

– Hoge hervalkans

– 2 jaren, 2e lijns :

• 40 % niet succesvol

• ¼ werkonbekwaam

• Conservatieve behandelingen : juiste waarde ?

Balague 1999, Vroomen 2002, Pinto 2012

Dworkin 2007 Suri 2012, Haugen 2012, Grovle 2013

Van Boxem RAPM 2014

• Hernia :

Cellichamen zenuwen in ganglion spinale

Hernia

Van Boxem RAPM 2014

I. (Sub)acute radicular pain: epidural corticosteroids

II. Chronic radicular pain: – pulsed radiofrequency treatment

– Neurostimulation

Interventional pain management

AVU sept 2009

Subacute

• Epidural corticosteroids : close to the inflammation

• Interlaminar

• Transforaminal

All epidural approaches :

• 23 RCT : high quality (GRADE)

- short term: + over placebo leg pain, disability

- long term: -

Pinto Ann. Int. Medic. 2012

Evidence



– Neurostimulation


Van Boxem RAPM 2014

Spinale ganglion :

Δ myeline, mitochondrien, microfilamenten, microtubuli

↗ ATF-3

5HT en NA ↗ C-Fos

↗ Met-enkephalinen

↘ OX-42 (microglia)

↘ glutamate – aspartate

Van Boxem Van Zundert RAPM 2014

PRF biological effects

Chronic radicular pain - radiofrequency

• Pulsed RadioFrequency (PRF) treatment adjacent to DRG: – PRF improves pain in patients with chronic lumbosacral radicular

pain

Van Boxem Pain Medicine 2014



– Spinal Cord Stimulation


Spinal cord stimulation: evidence

• Pts with FBSS: SCS vs reoperation – SCS more effective, less cross over to surgery

• Pts with FBSS: SCS vs CMM – Less cross over in SCS group to CMM, more pts satisfied.

North et al. Neurosurgery 2005 Kumar et al. Pain 2007

Conclusion radicular pain

• Interventions : • subacute radicular pain: epidural steroids efficient but short-term

• Chronic radicular pain:

pulsed radiofrequency treatment

Spinal cord stimulation: FBSS

Content

I. Interventions

II. Spinal pain



Facet pain

• Innervation : medial branch

Goldthwaite J.Boston Med Surg J. 1911 Ghormley R. JAMA. 1933 Cohen SP, Anesthesiology. 2007

Diagnosis

• History: axial low back pain potentially with referral pattern

• Clinical examination: lumbar paravertebral tenderness

• Diagnostic Medial Branch Block

Van Kleef et al. Pain Practice 2010

Treatment facetpain

• Radiofrequency of medial branch for lumbar facet joint pain

Content

I. Interventions

II. Spinal pain



III. Non- Spinal pain

• Trigeminal neuralgia

• Cervicogenic headache

• Occipital neuralgia

Indications interventional pain therapy

I. Head and face – Trigeminal neuralgia

– Cervicogenic headache

– Occipital neuralgia

Trigeminal neuralgia


Description :

• recurrent unilateral brief electric shock-like pains

• abrupt in onset and termination

• limited to the distribution of one or more divisions of the trigeminal nerve

• triggered by innocuous stimuli.

International Headache Society, Cephalalgia 2013

Pathofysiology

IHS, Cephalalgia 2013

Classical : Neurovasculair compression : superior cerebellar artery

Painful trigeminal neuropathy

neural damage

(post)herpetic

MS (7%)

space-occupying lesion

Imaging

• MRI

– For exclusion of the symptomatic variant

– Support for the decision of surgical decompression

– 30% has also compression of the asymptomatic side.

ganglion pterygopalatinum

Gasserian ganglion

Trigeminal neuralgia : Gasserian ganglion

RCT’s on Trigeminal neuralgia

• Comparison of pulsed radiofrequency with conventional radiofrequency in the treatment of idiopathic trigeminal neuralgia.

→ RF > PRF

Erdine, S., et al. Eur J Pain 2007

I. Head and face

– Trigeminal neuralgia

–Cervicogenic headache

Overview

Anamnesis

• Pain begins in the neck radiates outward to fronto-temporal and possibly to the supra-orbital area.

• Nagging and nonpulsating

• Occurs in attacks of unpredictable duration (hours to days)

• Pattern of attacks can change into a chronic fluctuating headache.

Physical examination

Interventional treatment

• Local injections : – occipital nerve – intra-articular facet

• Radiofrequency treatment – Facet : ramus medialis (medial branch) dorsal ramus of the segmental

nerve

– DRG : ganglion spinale

RF Medial branch of dorsal ramus

• RCTs

– RF facet vs sham no difference 3, 12 and 24 months (no examination of facet joints!)

– RF facet ± RF DRG C2-C3 vs injection of n. occipitalis ± TENS

• At 1 year FU significant pain reduction in 53% RF patients and in 46% of injection/TENS patients

Hildebrandt. Man Med 1986; 2: 48-52 Van Suijlenkom et al. Funct. Neurol. 1998; 13 : 297- 303 Stovner et al. Cephalgia 2004; 24: 821-830 Haspeslagh et al. BMC Anesthesiol. 2006; 16: 1

Overview

I. Head and face

– Trigeminal neuralgia

–Cervicogenic headache

–Occipital neuralgia

Local injections Steroid or PRF Occipital nerve ?

• RCT LA/saline + PRF vs LA/steroid + sham PRF

• N= 81

• Outcome : PRF > steroid – Average occipital pain : 6weeks- 6 months

– Worst occipital pain : 3 months

– Average overall headache : 6 weeks

Cohen Pain 2015

Stimulation n. occipitalis

• Systematic review : 9 studies (level III)

Stimulation is a treatment option after failure conservative approach

Sweet Neurosurg 2015

interventional treatment chronic pain - zol · anamnesis • pain begins in the neck radiates...

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