Disclaimer1. Proper consent that, their photographs may be

used for teaching (presentation before other doctors) and scientific publications has been taken from the patients shown in the procedures.

2. I do not have any financial obligations towards company or their products named during presentation.

3. I acknowledge that, some of the material in this presentation is contributed by two leading pain physicians, Dr Gautam Das, MD FIPP (India) and Dr Vikram B Patel, MD FIPP (USA).

Interventional Pain Management; Way forward to manage chronic pain

Dr Ashok Jadon, MD DNB

Aesculap Academy IPM Fellowship

Sr Consultant Anaesthesia

Objectives

• Introduction of IPM– Its Scope– IPM in LBP

• Our Experience– Gapes

• Resource• Results

•Interventional Pain Management is some minimally invasive procedures which gives permanent/long term pain relief.

What it is ?

Non-opioids

Weak opioids +/- non-opioids

Strong opioids

Recovery

Operation

Treatment of Low Back Pain

World of Misery Non-pharmacological methods

Non-opioids

Weak opioids +/- non-opioids

Strong opioids

Recovery

Operation

Treatment of Pain

Non-pharmacological methods

It fills the gap between pharmacologic management of pain & more invasive operative procedure.

IPM are group of procedures with different mechanism of actions

Targeted delivery of drugs.

Aims to correct the pathology

Blocking of nerve

signals corrects neuropathy.

Steroids, Neurolytics, Local anaesthetics

Adhesinolysis, Vertebroplasty, Kypho-plasty

LA, Ozone Neurolytics, Radiofrequency ablation, Chemical & Electrical Neuromodulation

Scope/ indications• Head & Neck

– Headache: nerve blocks, PNS, – Gasserian ganglion block -trigeminal neuralgia– Cervical epidural, facet, RF, stellate gn block

• Thorax– Cryo Intercostal nerves, Facet, RF

• Pelvic pain: hypogastric plexus block

• Abdominal Cancer pain: celiac plexus

• Low Back Pain…………

Structures responsible for LBP

Major Causes of Low Back Pain• Facet joint arthropathy 15-45%

• Interval disc disruption 25-40%

• Sacro-Iliac joint arthropathy 15-30%

• Disc prolapse/ herniated disc/ slipped disc-2-5%

• Chronic Regional Pain Syndrome 2-8%

• Failed Back Surgery Syndrome 1%

• Pyriform syndrome

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Low Back Pain: Red Flags

• Possible fracture • Possible tumor or infection. • Bladder or Bowel dysfunction.• Severe or progressive neurologic dysfunction in

the legs.• Major motor weakness in quadriceps, plantar

flexors, evertors, and dorsiflexors.

Facet Joint InterventionsFacet Joint Interventions

• Intra-articular injectionsIntra-articular injections• Medial branch blockMedial branch block• Radiofrequency ablationRadiofrequency ablation

•Facet joint (zygapophysial)zygapophysial) •arthropathy 15-45%

Facet Joint InterventionsFacet Joint InterventionsLumbarLumbar

“Scottie Dog” View

C-arm should be rotated such a way so that facet joint is opened up maximally & end

plate of two adjacent vertebrae are in line.

Disc space between L4-L5 disc

Facet joint

Inferior end plate of L4 Vertebra

Superior end plate of L5 Vertebra

Facet Joint InterventionsFacet Joint InterventionsLumbar - RFLumbar - RF

L5

L4

S1

Radiofrequency Ablation (RF)

LBP ; Disc(Disc Cause LBP 25% to 45%)

Disc procedures• Epidural Steroid Inj.

• Selective Nerve root / transforaminal Inj.

• Discectomy

• Ozone nucleolysis

• RF procedures (Intradiscal Electrothermal Annuloplasty (IDEA),

or IDET

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Epidural ApproachesEpidural Approaches• Decrease

phospholipase A2 and complements

• Histamine Antagonist• Anti-inflammatory• Local Anaesthetic• Volume effect• Non-specific

Midline Interlaminar L5-S1

Transforaminal ApproachTransforaminal Approach

Transforaminal ApproachTransforaminal Approach

Ozone Nucleolysis

• It breaks down proteo-glycan bridges in the nucleus pulposus.

• As a result disc shrinks and mummified and there is decompression of nerve roots.

• It has high success rate(88%).• It is less invasive.• Fewer chances of recurrences. • Remarkably fewer side effects.

Intradiscal Procedures

• Intradiscal coagulation with conventional RF

• Intradiscal electromagnetic field (with Pulsed RF)

• Posterior annuloplasty (Coblation)

• IDET (Intradiscal electro-thermal coagulation &

I-DET

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Percutaneous Disc Decompression/Discectomy

17G needle introduced, motorized probe is introduced

It breaks the nucleus pulposus into fine particles

and sucks it out.

Vertebroplasty

POST LAMINECTOMY SYNDROME

Mechanical lesion

* Spinal stenosis

* Recurrent disk

* Spinal instability

Often can be corrected with additional surgical procedures

Non mechanical lesion

*Epidural fibrosis

* Arachnoiditis

* Neuropathic pain

*Psychosomatic pain

Not amenable to surgical treatment

POST LAMINECTOMY SYNDROME

Surgery (success rate 20%-30%) Interventions Management of FBSS * Epidural adhesinolysis: Fluoroscopic hydrodynamic

process using corticosteroids, hypertonic saline, L.A., hyaluronidase.

Epidural Adhesinolysis

NormalFilling defect in FBSS

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POST LAMINECTOMY SYNDROME

Epiduroscopy

POST LAMINECTOMY SYNDROME

Advanced pain modulation therapies

• Spinal cord stimulation (SCS); Chronic neuropathic pain of a non-structural nature*

• Intrathecal drug delivery system; persistent nociceptive pain who had structurally successful surgery. (spinal administration of opioids via implantable continuous drug

Spinal cord stimulator

Intrathecal pump

Evidence based practicesOutcome studies

• Even in patients of PIVD with neuro-deficits (numbness & weakness) there is equal chance of cure between surgical and non-surgical managements.

• 83% of patients for whom urgent surgery was recommended could avoid surgery & still achieved good/excellent outcome.

• A large scale English study showed that 86% good outcome with non-surgical treatment.

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Results & Gapes

• 50% relief in 50% of the patient for reasonable duration (3wks 14 months)

• Our results

• Gapes:– Vertebroplasty and Discectomy kits– RF

• Future……