interventional approach to back pain dr surange

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