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Interven’onal Procedures in Chronic Pain Dr Brendan Moore Specialist Pain Medicine Physician Adjunct Associate Professor University of Queensland

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Interven'onal  Procedures  in  Chronic  

Pain      Dr  Brendan  Moore  Specialist  Pain  Medicine  Physician  Adjunct  Associate  Professor  

 University  of  Queensland  

Degenera've  Lumbar  Back  Pain  

Origins  of  lumbar  pain  

•  Degenera've  Discs  •  Vertebral  fractures  •  Spinal  /  Foraminal  Stenosis  

•  Disc  Bulge  /  Prolapse  •  Facet  Joint    •  Muscle  /  So@  'ssue    

Invasive  Treatment  Op'ons  

•  Surgery  •  Facet  Joint  Injec'on  •  Radiofrequency  medial  branch  abla'on  •  Epidural  /  Caudal  steroid  •  Vertebroplasty  •  Coeliac  /  Lumbar  Sympathe'c  Plexus  Blocks  •  Sacro-­‐iliac  Joint  injec'on  

Posterior  Elements  

•  Facet  Joints  frequently  implicated  in  pain  •  Mechanical  back  pain  with  upper  leg  and  buNock  radia'on  

Appropriate conditions for interventional pain procedures

•  Aseptic conditions

•  Monitored sedation with anaesthetist in attendance

•  Image intensifying X-ray or CT guidance

•  Appropriate analgesia

Procedures

•  Epidural injections –  Cervical, Thoracic, Lumbar, Caudal

•  Facet joint injections

•  Sacroiliac joint injections

•  Medial branch blocks

•  Radiofrequency nerve ablation

Epidural injections

•  Most effective in the presence of nerve root compression and spinal stenosis

•  Increased efficacy if given in the first weeks of the onset of pain

•  Effects of the injection tend to be temporary (1 week to 1 year)

•  Can be beneficial in providing relief for patients during an episode of severe back pain

•  Allows patients to progress in their rehabilitation

Lumbar epidural injection

•  18G or 16G Toohey needle

•  Radio-opaque contrast to confirm position

•  Injection and distribution of local anaesthetic and steroid to nerve root

Lumbar  Epidural  Injec'on  

Caudal  Epidural  Injec'on  

Facet joint injections

•  Back pain originating from facet joints

•  Low back pain (unilateral or bilateral) and no root tension signs or neurological deficits

•  Pain usually being aggravated by extension of the spine

•  Facet joint injection may reduce inflammation and provide pain relief

•  Therapeutic goal and potential benefit –  Temporary relief from pain –  Patient may proceed into an appropriate exercise program"

Facet  Joint  Injec'on  

•  Primarily  diagnos'c  •  25G  Spinal  needle    •  LA  +  Steroid  •  Steroid  confers  possible  longer  term  benefit  

Sacroiliac joint injection

•  Indicated with referred pain

•  Pain referral pattern – area around and just caudal to the posterior superior iliac spine

•  Referred pain in the low back, buttocks, abdomen, groin or legs

•  In some patients, S-1 joint injections can provide significant pain relief"

Sacroiliac joint injection

•  Diagnostic

•  25G spinal needle

•  Local anaesthetic + steroid

•  Steroid indicative of possible long-term benefit

Sacro-­‐iliac  Joint  Injec'on  

Medial branch blocks

•  Medial branch nerves are the very small nerve branches that controls sensation of the facet joint

•  Indicated in low back pain (unilateral or bilateral)

•  Pain usually aggravated by extension of the spine

•  Medial branch blocks are a diagnostic procedure

•  Can provide temporary pain relief

Medial branch nerve ablation

•  Diagnostic medial branch blocks

•  Local anaesthetic + steroid

•  Progress to radiofrequency ablation if diagnostic block indicative of long-term benefit

Medial  Branch  Nerve  Abla'on  

•  Denerva'on  of  Medial  Branch  via  Radiofrequency  Neurotomy  

Radiofrequency neurotomy

X-ray to confirm needle position – AP and oblique views

Test stimulation – 2.0 Hz 0–2 volt to test for motor nerve contact

Lesion 85°C for 90 seconds

Cervical radiofrequency neurotomy

Position for C2/3 and C3/4 facet joint radiofrequency

Cervical  Radiofrequency  Neurotomy  

Cervical radiofrequency neurotomy – lateral view

Marker shows needle at C2/3 facet joint

Coeliac  Plexus  Block  

Facet joint injection

•  Diagnostic

•  25G spinal needle

•  Local anaesthetic + steroid

•  Steroid indicative of possible long-term benefit

Elena Yusim – Pain Psychologist

The Psychology of Pain Management

Strategy Psychosocial  Assessment    

§   medical  history  –  any  flags/concerns/drug  seeking  §  Thinking  paNerns  –  helpful  or  unhelpful  §  Social  interac'ons  -­‐  family,  friends,  spouse  §  Behaviours  -­‐    ac'vity  levels,  avoidance,  anything  harmful  §  Sleep  paNerns  –  any  changes      

Testing §  Beck  Depression  Inventory  –  BDI  §  Depression,  Anxiety  and  Stress  Scale  –  DASS  §  Personality  Assessment  Inventory  -­‐  PAI  

Reality Check

§ Why  is  the  pa'ent  here?  § Mo'va'on  to  RTW?  §  Any  secondary  gain  from  sick  role?  §  Are  they  prepared  to  do  the  hard  work?  §  Do  they  expect  to  be  fixed?  § What  do  they  agree  to,  if  they  don’t  comply?  

Invisible Tool Kit

§  Goal  se\ng  §  Pacing  §  Journaling  §  Thought  Management  –  CBT,  ACT  §  Relaxa'on    and  self  regula'on  strategies  §  Relapse  preven'on  planning    

Opioids  in  Chronic  Pain      Dr  Brendan  Moore  Pain  Medicine  Specialist  Physician  Adjunct  Associate  Professor  

 University  of  Queensland  

Opioid prescribing: dose limits and considerations  

Suggested maximum opioid dose

•  Consult a Pain Medicine Specialist if higher doses considered necessary

1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010

Drug Maximum dose for GP prescription

Morphine 120mg daily Oxycodone 80mg daily Hydromorphone 24 mg daily Methadone 40mg daily Fentanyl transdermal patch 25 mcg/hr applied every 3 days Buprenorphine transdermal patch 40 mcg/hr applied weekly Tramadol 400 mg daily

Dose conversion

Morphine equivalence to

Ratio morphine : named opioid

Examples of equivalent doses

Codeine 1:6 Morphine 10 mg Codeine 60 mg Oxycodone 1.5:1 Morphine 60 mg Oxycodone 40 mg Hydromorphone 5:1 Morphine 60 mg Hydromorphone 12 mg

Tramadol 1:5 Morphine 10 mg Tramadol 50 mg Fentanyl Morphine 90 mg Fentanyl 25 mcg/h Buprenorphine 75:1 Morphine 9 mg Buprenorphine 5 mcg/h

Methadone 3:1 Morphine 60 mg Methadone 20 mg

1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010

Opioid trial guidelines

•  Commence trial with low dose sustained-release opioid

Use a lower dose and titrate slowly in patients

who are:

•  Elderly •  Taking other CNS depressants •  Opioid naïve •  Have severe hepatic or renal dysfunction

1.  Graziotti & Goucke, 1997.

Review of opioid trial

•  Discuss progress and outcomes

•  Functional goals achieved? •  Medication used responsibly? •  Discuss risks / benefits of continued therapy •  Assess 4 ‘A’s1

–  Analgesia –  Activity –  Adverse effects –  Aberrant drug behaviours

1. Gourlay & Heit, 2005.

Federal requirements

PBS prescription Restricted benefit •  Chronic severe disabling pain not responding to non-

narcotic analgesics (treatment <12 months) •  If treatment required beyond 12 months, patient must be

reviewed by a second medical practitioner

•  Authority required when prescribing increased quantities of opioid and/or repeats –  By phone – 1 month’s supply with no repeats –  In writing – 1 month’s supply with 2 repeats

•  Short term supply can be prescribed without an authority

Department of Health and Ageing, 2008.

State requirements - QLD

•  If intend to prescribe S8 drugs for longer than 8 weeks, forward a “Report to the Chief Executive” through the Drugs of Dependence Unit (DDU)

•  A treatment approval from the Chief Executive is required prior to treating, for any controlled drug for a patient considered to be drug dependent

•  For approvals and “Reports to the Chief Executive” contact the Drugs of Dependence Unit –  Phone 3328 9890 –  Fax 3328 9821

Preventing doctor-shopping

Medicare Australia Prescription Shopping Information Service

•  If patient suspected of getting medicine in excess of medical need, contact the Prescription Shopping Information Service: –  Complete and sign the registration form available at

www.medicareaustralia.gov.au •  Registration confirmed within 2 business days (fax) or by

mail –  Information Service available 24/7 for registered GPs to:

•  Find out if patient has been identified under the Prescription Shopping Program

•  Receive information on the amount and type of PBS medicine recently supplied to that patient

(  1800  631  181    

Summary – opioid pathway

Multidimensional assessment GP +/– practice nurse +/– others

Opioid trial

Maintenance therapy

Authority to Prescribe

Review

Exit from pathway: i.  Goals of therapy not

achieved in trial or maintenance phase

ii.  Predominance of psychosocial issues

iii.  Evidence of aberrant drug related behaviour

Integrated Pain Service, 2008.

Is the patient suitable for opioid therapy?

State / territory health departments

State / territory

Department Contact

ACT Pharmaceutical Services Section, ACT Health ( 02 6207 3974

NSW Pharmaceutical Services Branch, NSW Health ( 02 9879 3214

8 www.health.nsw.gov.au/publichealth/ pharmaceutical

NT Poisons Control Unit, Department of Health & Community Services

( 08 8922 7341 8 www.health.nt.gov.au

QLD Drugs of Dependency Unit, Queensland Health ( 07 3896 3900

SA Drugs of Dependence Unit, Drug & Alcohol Services, Department of Health

( 1300 652 584 8 www.health.sa.gov.au

TAS Pharmaceutical Services Branch, Department of Health & Human Services

( 03 6233 2064

VIC Drugs & Poisons Unit, Department of Human Services

( 1300 364 545 8 www.health.vic.gov.au/dpu

WA Drugs of Dependency Unit, Department of Health ( 08 9388 4985