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interventional procedures

interventional procedures



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  • What are the structures and their pathology responsible for low back pain

IPM IPM Presentation Transcript

  • Disclaimer
    • Proper consent that, their photographs may be used for teaching (presentation before other doctors) and scientific publications has been taken from the patients shown in the procedures.
    • I do not have any financial obligations towards company or their products named during presentation.
    • I acknowledge that, some of the material in this presentation is contributed by two leading pain physicians, Dr Gautam Das, MD FIPP (India) and Dr Vikram B Patel, MD FIPP (USA) .
  • Interventional Pain Management; Way forward to manage chronic pain Dr Ashok Jadon, MD DNB Aesculap Academy IPM Fellowship Sr Consultant Anaesthesia
  • Objectives
    • Introduction of IPM
      • Its Scope
      • IPM in LBP
    • Our Experience
      • Gapes
        • Resource
        • Results
    • Interventional Pain Management is some minimally invasive procedures which gives permanent/long term pain relief.
    What it is ?
  • Non-opioids Weak opioids +/- non-opioids Strong opioids Recovery Operation Treatment of Low Back Pain World of Misery Non-pharmacological methods
  • Non-opioids Weak opioids +/- non-opioids Strong opioids Recovery Operation Treatment of Pain IPM Non-pharmacological methods It fills the gap between pharmacologic management of pain & more invasive operative procedure.
    • Targeted delivery of drugs.
    • Aims to correct the pathology
    • Blocking of nerve signals corrects neuropathy.
    • Steroids, Neurolytics, Local anaesthetics
    • Adhesinolysis, Vertebroplasty, Kypho-plasty
    • LA, Ozone Neurolytics, Radiofrequency ablation, Chemical & Electrical Neuromodulation
    IPM IPM are group of procedures with different mechanism of actions
  • Scope/ indications
    • Head & Neck
      • Headache: nerve blocks, PNS,
      • Gasserian ganglion block -trigeminal neuralgia
      • Cervical epidural , facet, RF, stellate gn block
    • Thorax
      • Cryo Intercostal nerves, Facet, RF
    • Pelvic pain: hypogastric plexus block
    • Abdominal Cancer pain: celiac plexus
    • Low Back Pain…………
  • Structures responsible for LBP
  • Major Causes of Low Back Pain
    • Facet joint arthropathy 15-45%
    • Interval disc disruption 25-40%
    • Sacro-Iliac joint arthropathy 15-30%
    • Disc prolapse/ herniated disc/ slipped disc-2-5%
    • Chronic Regional Pain Syndrome 2-8%
    • Failed Back Surgery Syndrome 1%
    • Pyriform syndrome
    www. pain india.net
  • Low Back Pain: Red Flags
    • Possible fracture
    • Possible tumor or infection.
    • Bladder or Bowel dysfunction.
    • Severe or progressive neurologic dysfunction in the legs.
    • Major motor weakness in quadriceps, plantar flexors, evertors, and dorsiflexors.
  • Facet Joint Interventions
    • Intra-articular injections
    • Medial branch block
    • Radiofrequency ablation
    • Facet joint ( zygapophysial)
    • arthropathy 15-45%
  • Facet Joint Interventions Lumbar “ Scottie Dog” View
  • C-arm should be rotated such a way so that facet joint is opened up maximally & end plate of two adjacent vertebrae are in line. Disc space between L4-L5 disc Facet joint Inferior end plate of L4 Vertebra Superior end plate of L5 Vertebra
  • Facet Joint Interventions Lumbar - RF L5 L4 S1
  • Radiofrequency Ablation (RF)
  • LBP ; Disc (Disc Cause LBP 25% to 45%)
  • Disc procedures
    • Epidural Steroid Inj.
    • Selective Nerve root / transforaminal Inj.
    • Discectomy
    • Ozone nucleolysis
    • RF procedures (Intradiscal Electrothermal Annuloplasty (IDEA), or IDET
    www. pain india.net
  • Epidural Approaches
    • Decrease phospholipase A2 and complements
    • Histamine Antagonist
    • Anti-inflammatory
    • Local Anaesthetic
    • Volume effect
    • Non-specific
    Midline Interlaminar L5-S1
  • Transforaminal Approach
  • Transforaminal Approach
  • Ozone Nucleolysis
    • It breaks down proteo-glycan bridges in the nucleus pulposus.
    • As a result disc shrinks and mummified and there is decompression of nerve roots.
    • It has high success rate(88%).
    • It is less invasive.
    • Fewer chances of recurrences.
    • Remarkably fewer side effects.
  • Intradiscal Procedures
    • Intradiscal coagulation with conventional RF
    • Intradiscal electromagnetic field (with Pulsed RF)
    • Posterior annuloplasty (Coblation)
    • IDET (Intradiscal electro-thermal coagulation &
  • I-DET
  • Percutaneous Disc Decompression/Discectomy www. pain india.net 17G needle introduced, motorized probe is introduced It breaks the nucleus pulposus into fine particles and sucks it out.
  • Vertebroplasty
    • Mechanical lesion
    • * Spinal stenosis
    • * Recurrent disk
    • * Spinal instability
    • Often can be corrected with additional surgical procedures
    • Non mechanical lesion
    • *Epidural fibrosis
    • * Arachnoiditis
    • * Neuropathic pain
    • *Psychosomatic pain
    • Not amenable to surgical treatment
    • Surgery (success rate 20%-30%)
    • Interventions Management of FBSS
    • * Epidural adhesinolysis: Fluoroscopic hydrodynamic process using corticosteroids, hypertonic saline, L.A., hyaluronidase.
  • Epidural Adhesinolysis Normal Filling defect in FBSS www. pain india.net
    • Epiduroscopy
    • Advanced pain modulation therapies
    • Spinal cord stimulation (SCS); Chronic neuropathic pain of a non-structural nature *
    • Intrathecal drug delivery system; persistent nociceptive pain who had structurally successful surgery.
    • (spinal administration of opioids via implantable continuous drug
    Spinal cord stimulator Intrathecal pump
  • Evidence based practices Outcome studies
    • Even in patients of PIVD with neuro-deficits (numbness & weakness) there is equal chance of cure between surgical and non-surgical managements.
    • 83% of patients for whom urgent surgery was recommended could avoid surgery & still achieved good/excellent outcome.
    • A large scale English study showed that 86% good outcome with non-surgical treatment.
    www. pain india.net
  • Results & Gapes
    • 50% relief in 50% of the patient for reasonable duration (3wks 14 months)
    • Our results
    • Gapes:
      • Vertebroplasty and Discectomy kits
      • RF
    • Future……
  • Thanks Thank you