New Therapies for Back Pain

David Sibell, MD, DABA, SCPMOHSU Spine Center

What is Pain?

• International Association for the Study of Pain definition:

Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Conceptualizing Chronic Pain

Tissue Disruption

Functional Disruption

Environment and Treatment

Expression of Pain

Where does Interventional Care fit??

• Multidisciplinary pain management– Medical/interventional– Rehabilitation– Behavioral medicine/psychological– Surgical

• Interventional care modalities– Neuropathic (nerve injury)– Spinal

Disc Herniation

• Vertebral discs usually cushion & allow movement

• When damaged, they may impinge on spinal nerves, causing radiating pain

Modic MT. Radiology 2007;245:43-61

Epidural Steroid Injection

Best for acute (recent onset) leg or arm pain

Not as effective for long term pain or central pain

Spinal (Facet Joint) Arthritis

• Joints on both sides, at every spinal level from head to sacrum

• Subject to gravity, time, and trauma• Can develop osteoarthritis• Also subject to rheumatological diseases

(like Rheumatoid Arthritis)• Cause axial (central) pain

Facet Arthritis Pain Patterns

Lumbar Cervical

Pathology of Zygapohyseal (facet) Joints

Subchondral hematoma Articular process fracture

Radiofrequency Facet Denervation

• Low risk, outpatient procedure• 2 phases

– diagnostic block– RF denervation

• About 75% of persons having ≥ 50% improvement with block get equivalent relief from denervation

• Effect lasts 12-18 months• Best when paired with physical therapy

Radiofrequency Facet Denervation for

Axial Spinal Pain

Cervical Medial Branch Denervation

Lumbar Medial Branch Blocks

Spinal cord stimulation

• A consideration for long-term, refractory pain due to – Nerve injury– Failed Back Syndrome– Some types of arterial insufficiency– Complex Regional Pain Syndrome

• 2 phase procedure– Trial phase– Implantation

• Preceded by Psychological evaluation

Generators

ANS

Boston Scientific

Medtronic

Leads

ANS Boston ScientificMedtronic

•Electrodes

•Lead

•Implanted Pulse Generator

Spinal Cord Stimulator Configuration

FBSS & Peripheral Vascular Disease

• Leg > back pain• But, with newer

technologies, back pain is better than in past.

• Lower extremity peripheral vascular disease

• Fewer amputations

Van Buyten J-P. JPSM 2006;31(4S):S25-29Ubbink DT. JPSM 2006;31(4S):S30-35

SCS outcomes in Complex Regional Pain Syndrome

• Initial benefit• Eventual relapse

Iraq & Afghanistan war injured vets with CRPS Dutch people with CRPS

Verdolin MH. Anesth Analg 2007;104:1557–60Kemler MA. NEJM 2006;354:

Syndrome X

• Less frequent angina

• Briefer duration of anginal episodes

• Less nitrate use

Sgueglia GA. Heart 2007;93;591-597

Chronic pain changes lives.Treatment should, too.

• Involve Pain Psychology to Assist Adaptation & Coping

• Develop Rehabilitation Program to Improve Pain and Function

• Mesh Surgical Care with Amplifying Resources.

• Use Interventional Treatments with Lasting Effects!

To make an appointment with the OHSU Spine Center or with Dr. Sibell:

Please Call (503) 418-1988