interventional approach to back pain dr surange
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Dr (Maj) Pankaj N Surange
MBBS, MD (Anesthesiology), FIPP (Hungary)Interventional Pain and Spine Specialist
Secretary, World Institute of Pain, India Chapter
www.ipscindia.com
Interventional Pain managementInterventional Pain management
Interventions are Minimally Invasive, Non Surgical and Target Specific procedures to
Diagnose and to treat Various painful conditions
It fills the gap between pharmacologic management
of pain & more invasive operative procedure
In USA, The Department of Health and Human Services Centers for Medicare
and Medicaid Services issued a memo March 4, 2005, including Interventional Pain Management specialists on the list of clinical specialties to be included in carrier advisory committees.
"Pain relief should be a human right, whether people are suffering from cancer, HIV/AIDS or any other painful condition,“
Important facts about pain management as the Speciality
Recognised as a 34th speciality in USA: American society of Interventional pain
physician
Pain as fifth vitalsign
Pain relief a human right – WHO (world health organization)
Intenational Association for study of Pain-1973
World Institute of Pain-1993Fellowship -2001
Semmelweis University, Budapest(Hungary)
FIPP-2009
CASE 1
• 36 Years, Executive
• Back pain with radiation to Left leg for 4 months.
• Lost his job.
• Progressively increasing and association with paresthesia.
Case 1-Contained Disc Herniation
.
Management : Disc Herniation
Under fluoroscopic Guidance Correct level of the prolapsed disc is identified
Needle is inserted into the centre of the Disc and ozone is Injected.Pain relief starts usually within one week and ozone takes 3-4 weeks for its complete effect
Percutaneous Ozonucleolysis + Transforaminal L5 and S1
Minimally invasive procedure using small needle and probe to remove disc material of prolapsed disc ,releasing pressure on nerves and relieving pain
in most of the patients of prolapsed/ bulging / slipped disc
Management : Disc Herniation
Percutaneous disc decompression
Percutaneous Disc Decompression
Rotating tip removes small portion of disc
material. Because only enough of the disc is removed to reduce pressure inside
the disc, the spine remains stable.
Insertion site covered with bandage.
Recovery is fast as unlike surgical decompression no bone or muscle is cut.
2-3 days of bed rest and may return to normal activity within one week.
Management : Case 1
Management : Case 1 Nucleotomy
Case 2
• 42 Yrs/ Male
• Back pain X 2 yrs
• No h/o radiation to legs
• Aggravating factors• Sitting > 40 min• Driving• Forward bending
Case 2- Discogenic Pain
Discogenic Pain
Management ;Case 2
• Intradiscal Ozone
By inhibiting inflammatory nociceptors
Intradiscal Electrotherapy (IDET)
Management : Discogenic Pain
Biculoplasty-
Management : Discogenic Pain
Facet Arthropathy secondary to Disc
degeneration• Disc bears 80% of weight• Facet joints bears 20 % of weight
A change in the intervertebral disc producesChange in the whole motion segment
MRI
Facet Arthropathy
• Low back pain- unilateral or bilateral• Tenderness over facet joints• Pain is deep, dull aching, difficult to
localize• Referred to the buttocks, groin, hip, or
posterior and lateral thigh.• Pain is more prominent in the morning
and with inactivity• May aggravate on extension after
forward flexion
Management- Facet Arthropathy
Inflammatory Type Degenerative type
Intra-articular Steroid
RF Ablation Median Branch
Case 3
• 56 yrs /Female• Severe radicular pain in Rt Leg• H/o frequent back pains• Sensory loss in L5 Distribution and
EHL- 4/5.• Known case of Rheumatoid Arthritis,
Ucontrolled DM, CAD, Interstitial Lung disease.
Intraspinal Synovial Cyst
Management :Case 3
• Percutaneous Transforaminal Cyst Aspiration
Case 4
• 70 Yrs male/ obese
• Back pain Rt > lt
• Radiation to rt thigh --- lat surf of rt leg
• Tossing on chair
• 1st Investigation ordered –MRI LS SPINE
MRI
Case 5
Physical Examination
Rt SI Joint Tenderness +++
Management- Case 4S I Jnt Injection
Case 5
• 35 Yrs/Female
• Known case of CA Cervix
• Metastasis
• Sudden onset of severe pain mid back
• No neurological deficit
Compression Fracture Vertebral body
Case 6
– 45 Yrs Male, only earning member – Traumatic Fracture D12 Vertebra– Totally bed ridden, Urinary catheter, Ryles
tube feed
Fracture D12 Vertebra
Vertebroplasty
Kyphoplasty
Case 6
• 55 yrs• DM X 25 Yrs• Progressively increasing stiffness
Lt Shoulder• Movements Painful • MRI –Joint capsule and Synovial
Thickening
PRF-Suprascapular Nerve
Case -7• 38 yrs male
• Low back pain radiating to both legs more on right side.
• He had history of disc prolapse of L4-5 & L5-S1 and has undergone surgery 2 times before (laminectomy, discectomy & excision of scar).
• Pain is increasing day by day.
• Repeated investigations & visit to 16 consultants for last 4 years has taken away all faith from any form of medical treatment.
• MRI-Epidural Fibrosis
Failed Back Syndrome (FBSS)
• Epidural Adhenolysis
Resistant Case of FBSS
Post op Trigeminal Neuralgia
– Pt presented after 2 years
of Surgery
– No improvement after surgery
– It was idiopathic TGN
•
RF Ablation –Trigeminal Nerve
Interventional Pain Procedures
• Limitations
• Contraindications
• Complications
• Not Alternative to Surgery
Welcome to ICIPM 2012, AIIMS, New Delhiwww.icipm2012.com
Dr (Maj) Pankaj N Surange MD, FIPPOrganizing Secretary, ICIPM 2012
Secretary, World Institute of Pain, India Section
Thanks
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