INTERVENTIONAL SPINE & PAIN MANAGEMENT
Dr Manish Raj MD, DA(gold medal), FISP, FMIS, FESS A Brief review by
Pain ??
“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
Acute vs chronic pain
pain that extends beyond the expected period of healing“ or more than 2 months
acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself or caused by occurrences such as traumatic injury, surgical procedures, or medical disorders
Chronic pain – A Disease
Chronic pain often out lives its original causes, worsens over time, and takes on a puzzling life of its own… there is increasing evidence that over time, untreated pain eventually rewrites the central nervous system, causing pathological changes to the brain and spinal cord, and that these in turn cause greater pain.
Even more disturbingly, recent evidence suggests that prolonged pain actually damages parts of the brain, including those involved in cognition.
Chronic pain facts …
Condition Number of Sufferers Source
Chronic Pain 100 million Americans Institute of Medicine of The National Academies (1)
Diabetes 25.8 million Americans (diagnosed and estimated undiagnosed)
American Diabetes Association
Coronary Heart Disease (heart attack and chest pain) Stroke
16.3 million Americans 7.0 million Americans
American Heart Association (2)
Cancer 11.9 million Americans American Cancer Society
1. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011
2. 2. Heart Disease and Stroke Statistics—2011 Update: A Report From the American Heart Association. Circulation 2011, 123:e18-e209, page 20. 3. http://www.painmed.org/patientcenter/facts_on_pain.aspx
Chronic pain facts…
The total annual incremental cost of health care due to pain ranges from $560 billion to $635 billion (in 2010 dollars) in the United States, which combines the medical costs of pain care and the economic costs related to disability days and lost wages and productivity.
More than half of all hospitalized patients experienced pain in the last days of their lives and although therapies are present to alleviate most pain for those dying of cancer, research shows that 50-75% of patients die in moderate to severe pain.
An estimated 20% of American adults (42 million people) report that pain or physical discomfort disrupts their sleep a few nights a week or more.
Chronic pain facts …
What is interventional pain management ?
Interventional pain management or interventional pain
medicine is a super-specialty of the medical specialty pain medicine, devoted to decrease or eliminate pain with use of invasive & non invasive techniques
This can be accomplished in following ways:
Interrupting the pain signal along a neural pathway
Remodeling anatomical source of pain
Neuroaugmentation (SCS, PNS)
Implantable drug delivery system
Conditions treated …
Back Pain : Slip disc /Sciatica /Lumbar Radiculopathy, Spinal stenosis
Disc herniation - protrusion/extrusion/sequestration/DDD
Facet Arthritis, Sacroilitis, Vertebral compression fracture,
Failed Back surgery syndrome, Spondylolysis, spondylolisthesis
Neck Pain : Cervical Radiculopathy,Cervical disc bulge,Cervical Facetal Arthritis, Trapezitis
Nerve Pain : Reflex Sympathetic Dystrophy/ Complex Regional Pain Syndrome, Post Herpetic & Intercostal Neuralgia, Diabetic neuropathy, Phantom limb pain
Musckuloskeletal Pain : Fibromyalgia, Scapulocoastal, Shoulder/Arm/Elbow/ Leg /Knee & foot chronic pain
Facial pain & headache: Trigeminal Neuralgia, Intractable Headaches (Migraine, Cluster, Chronic Daily , cervicogenic , occipital neuralgia, Tension)
Cancer & other pain : Cancer (Abdominal,pelvic,thoracic), Post chemotherapy pain, Ischemic leg pain, Any pain more than 3 months
Treating Chronic pain - conservative
Interventions
Injections: Image Guided ( Fluroscopy/ USG Guided)
- Epidural( Transforaminal/ Interlaminar at cervical spine)
- Diagnostic block ( Pain Mapping) at nerve ,ganglion, muscles
- Neurolysis, joints proliferation
- Discography
Radiofrequency ablation: High frequency alternating current
- Trigeminal/celiac/splanchnic/hypogastric/stellate /DRG ganglion
Minimally invasive spine & pain procedures:
- Percutaneous disc modulation ( Nucleoplasty, Dekompressor,
Hydrodiscectomy, Disc-Fx, Nucleotomy, Ozone nucleolysis)
- Endoscopic discectomy ( Band- Aid surgery)
- Spinal cord & peripheral nerve stimulator , Intrathecal pump,
- Vertebroplasty, Kyphoplasty
Back pain - Causes
Disc : Disc herniation of all types Bulge, Protrusion, Extrusion, Sequestration
Degenerative disc disease, Spinal stenosis
Bone – Verebral compression fracture, Trauma
Joints – facetal arthritis, sacroilitis
Muscles – Quadratus lumborum, Psoas, Piriformis
Another cause of back problems… Trauma
It is also possible to injure your back due to accidents.
Natural History of LBP
Acute LBP
inflammatory or neuropathic injury
resolves spontaneously with minimal treatment
Intermittent, relapsing LBP
more challenging diagnostic and treatment dilemma
precipitates symptomatic care and more aggressive interventions aimed at specific underlying pathology
Unremitting, recurring chronic LBP
structural, neurophysiological, and biopsychosocial pathology
requires management at all these levels
major public health problem
LBP Patient Treatment Prototypes
Chronic axial LBP pain does not extend beyond mid-buttock
absence of radicular pain or sensory symptoms below the knee
Chronic axial LBP with radiation pain with radiation beyond mid-buttock
absence of radicular pain or sensory symptoms below the knee
Chronic axial LBP with radicular component radicular pain or sensory symptoms below
the knee
Structure of Lumbar Spine
Basic functional units of spine—motion segments—consist of two posterior zygapophyseal (facet) joints and an intervertebral disc, forming a tri-joint complex
Zygapophyseal joint
Disc Herniation
Lumbar Structural Pathology and Degenerative Cascade
In all individuals, there is natural, progressive degeneration of the motion segments over time
This results in anatomic, biochemical, and clinical sequelae
Although lumbar motion segment degeneration is not a normal process, it may not be painful
Three phases of degeneration
Dysfunction
Instability
Stabilization
Risk Factors
Pregnancy
Poor physical conditioning
Poor movement techniques
Poor posture
Occupation
Previous back injuries
Others – spinal disorders (e.g. scoliosis, osteoporosis, spondylosis)
Considerations in the Clinical Assessment and Diagnosis of
Chronic LBP
Medical History
General
Neurologic
Psychosocial
Pain Scales/Questionnaires
Factors in the Elderly
Physical Examination
Neurologic
Diagnostic Studies
Evaluation of the Elderly
Goals of Clinical Assessment
Cervical Radiculopathy
Cervical Facetal Arthritis
Treatment ladder (Modified….)
Diagnostic blocks
Epidural steroids
Radiofrequency technigues
Neurostimulation
techniques
Neuroaxial
medication
Interventional Therapies
ADJUVANT ANALGESICS + PATIENTS EDUCATION
Spine Pain Treatment
Neural blockade
selective nerve root blocks
facet joint blocks, medial branch blocks
Neurolytic techniques
radiofrequency neurotomies
pulse radio frequency
Stimulatory techniques
spinal cord stimulation
peripheral nerve stimulation
Intrathecal medication pumps
delivery into spinal cord and brain via CSF
Minimally invasive
Percutaneous disc
modulation ( Nucleoplasty, Dekompressor, Disc-Fx, Hydrodiscectomy, Nucleotomy, Ozone nucleolysis, IDET, Disctrode)
Endoscopic discectomy
(Band- Aid surgery)
Vertebroplasty, Kyphoplasty ,
Open spine surgery
STEP UP ALGORITHM
North american spine society guidelines 2014
Minimally Invasive spine techniques “Daniel Kim”
Epidural Lumbar & cervical
o Usually performed utilizing fluoroscopy
o No sedation vs conscious sedation
o Can be therapeutic or diagnostic
Selective root sleeve tranforaminal epidural Cervical Epidural
Joints Interventions
Facet Joint RF Ablation Sacroiliac joint injection ( Arthrogram)
Cervical Facet Injection (RFA)
OZONE NUCLEOLYSIS
HYDRODISCECTOMY
DECOMPRESSOR DISCECTOMY
Intradiscal Electrothermal coagulation (IDET) & LASER
Nucleoplasty - Lumbar
Cervical Nuceloplasty
Disc modulation results…..
ENDOSCOPIC DISCECTOMY
SPINAL CORD STIMULATOR
Intrathecal pump
Vertebral compression fracture
Vertebroplasty & Kyphoplasty
Vertebral augmentation
Nerve pain( Neuropathy)
Trigeminal Neuralgia
CRPS
Post Herpetic Neuralgia
Diabetic neuropathy
Neuropathic pain
Radiofrequency Ablation
Trigeminal ganglion Rhizotomy
EVIDENCE BASED GUIDELINES FOR
INTERVENTIONAL PAIN MEDICINE
EFNS guidelines on neurostimulation therapy for neuropathic pain.
Cruccu et all. Eur J Neurology 2007;14:952-70.
Polyanalgesic consensus conference 2007: recommendations for the management of pain by intathecal (intraspinal) drug delivery: Report of an interdisciplinary expert panel.
Deer et al. neuromodulation 2007;10:300-328
Evidence-based guidelines for interventional pain medicine according to clinical diagnoses.
Van Kleef et al. Pain Practice 2009;9:247-51.
Evidence based medicine. Trigeminal neuralgia.
Van Kleef et al. Pain Practice 2009;9:252-9.
Comprehensive evidence-based guidelines for interventional techniques in the management of chronic pain.
Manchikanti et al. Pain Physician 2009;12: 699 (in press).
summary
Chronic Pain is a very complex disease, not a symptom
Progress is focused on targeting treatment at the mechanisms that produce pain rather than ameliorating the symptoms
Biopsychosocial & multispeciality approach is critical for the successful management of chronic Pain
Current standards & future in chronic Pain treatment include Uses of new & multimodal agents
Early Interventions to reduce incidence of chronic pain
uses of Modern techniques
Constant research for better understanding of brain imprint & objectifying pain
Thank you