Interventional Procedures for

Spine Pain Spine Pain Moises lustgarten, md

Medical director

Center for Pain management at Baptist Hospital

Financial Relationship disclosure

!  Nothing to disclose

Learning objectives

!  Be able to identify those patients most likely to benefit from interventional modalities

!  Understand the differences between the various

procedures used to diagnose and treat LBP

!  Recognize limitations to each procedure

!  Develop strategies to maximize treatment outcomes

Epidemiology

!  Major medical problem: > 5 million people affected

!  Major economic problem: >$25 billion per year

!  FBSS:

!  200,000 patients undergo back surgery every year

!  20-40% persistent pain or recurrent pain:

!  Erroneous diagnosis Radiculitis

!  Column instability Recurrent herniation

!  Erroneous location Arachoiditis

!  Epidural fibrosis

Lumbar Spine Anatomy

!  Bone / Vertebrae

!  Disc

!  Annulus

!  Nucleus Pulposus

!  Muscles / Ligaments

!  Spinal Nerve Roots

Lumbar Spine Anatomy

cross-section

Lumbar Spine Anatomy

!  Facet joint

!  Zygopophyseal joint

!  Synovial

LBP

!  Sacroiliac Joint

!  Tight, Synovial

!  Ligaments

!  “SI Dysfunction”

Interventional Pain Procedures

!  Interventional modalities to identify and interrupt pain pathways

!  Nerve stimulation

!  Nerve ablation

!  Dorsal column stimulation

!  Selective epidural injection

!  Selective nerve root isolation

!  Percutaneous decompression

Common Procedures

!  Selective nerve root blocks

!  Joint injections

!  Ganglion injections

!  Local anesthetic infusions

!  Implantable intrathecal pumps

!  Spinal Cord Stimulation

!  Radiofrequency Neurolysis

Common Procedures Center for Pain Management of South Florida

!  Epidural steroid

injections

!  Permanent epidurals

!  Facet Joint Injections

!  Epidural blood patch

!  Trigger point injections

Interventional Failures

!  While interventional treatments may provide

excellent relief there is a subset of patients

that will require pharmacological

management

Trigger Point Injections

!  Most basic intervention known to help with

myofascial pain syndrome

!  Different types of medications and/or

combination of different pharmacologic

agents: local anesthetics +/- steroids +/-

opioids, botulinum toxin

Epidural Steroid Injection

!  The Epidural injection or catheter is a versatile technique than can be utilized for types of acute or chronic pain.

!  They are most well known for labor and delivery

!  They can also be utilized to deposit anti- inflammatory medication around the spinal nerves

Epidural Steroid Injection

!  Epidur al steroid injections are used for a number of chronic pain states.

!  T h e y a r e m o s t e f f e c t i v e f o r b u l g i n g o r h e r n i a t e d d i s k s , a n d n e r v e r o o t irritation

Anatomy

!  Contains fatty tissue, venous plexus, lymphatics and dural projections of spinal nerve roots

Epidural Injection

Epidural Steroid Injection

Thoracic epidural Injection

Cervical Epidural Injection

Selective Nerve Root Block

Selective Nerve Root Block

Facet Joint blockade

!  Local anesthetic blockade of the joint or innervating nerves helps make the diagnosis

!  Intrarticular or periarticular steroid injections may provide prolonged relief

!  Cryo or radiofrequncy dennervation of the medial branch nerves is an option if local anesthetic blockade gives good but temporary relief

Facet JOINT ANATOMY

Facet Block

Facet Block

Cervical Facet Block

Radiofrequency Denervation

Lumbar Facet joints

Radiofrequency Denervation

Cervical Facet Joints

Sacroiliac Joint Injection

Sacroiliac Joint Injection

Lumbar Discography

Discography

INTRADISKAL

PROCEDURES

!  PERCUTANEOUS DISK DECOMPRESSION:

LASER, NUCLEOPLASTY

!  THERMAL ANNULAR DISRUPTIONS (IDET)

Dorsal Column Stimulation or

Spinal Cord Stimulation

Electrodes placed

w i t h i n t h e

e p i d u r a l s p a c e

can alleviate pain

in a wide variety of

locations.

They substitute pain

w i t h a m o r e

p l e a s a n t

vibration.

Spinal Cord Stimulation

Intrathecal Pumps

!  Proximal end is in the CSF !  Allows for smaller doses

!  Catheter is Tunneled under the Skin

!  Distal ends attached to the Pump, which is subcutaneous

!  No external pump

!  Rescues are not given via the Pump, usually, oral

!  Refilled approximately every 4-6 weeks

Intrathecal Pumps

!  New advances in pump technology have led

to design applications which have resulted

in smaller pump sizes

!  However pump capacity has increased

!  Increasing patient comfort and allowing

for less frequent need for refilling in

certain cases

Conclusion

!  Proper diagnoses is required for appropriate intervention to

provide optimal relief.

!  From simple trigger point injections to a highly complex

spinal cord stimulation are very effective if chosen properly

!  Low back pain treatment is multifocal, can be managed, but

very difficult to treat and cure.

References

!  Interventional Therapies for Chronic Low Back Pain: A Focused Review (Efficacy and Outcomes), Vikram B. Patel, Ronald Wasserman and Farnad Imani.

Anesth Pain Med. 2015 Aug; 5(4): e29716

An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations, Laxmaiah Manchikanti et al.

Pain Physician 2013, 16:S49-S283

Questions

!  Moises Lustgarten, MD

!  E-mail:

!  Center for Pain Management at Baptist Hospital

!  305 279-3223