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