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

    1. 1. Disclaimer <ul><li>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. </li></ul><ul><li>I do not have any financial obligations towards company or their products named during presentation. </li></ul><ul><li>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) . </li></ul>
    2. 2. Interventional Pain Management; Way forward to manage chronic pain Dr Ashok Jadon, MD DNB Aesculap Academy IPM Fellowship Sr Consultant Anaesthesia
    3. 3. Objectives <ul><li>Introduction of IPM </li></ul><ul><ul><li>Its Scope </li></ul></ul><ul><ul><li>IPM in LBP </li></ul></ul><ul><li>Our Experience </li></ul><ul><ul><li>Gapes </li></ul></ul><ul><ul><ul><li>Resource </li></ul></ul></ul><ul><ul><ul><li>Results </li></ul></ul></ul>
    4. 4. <ul><li>Interventional Pain Management is some minimally invasive procedures which gives permanent/long term pain relief. </li></ul>What it is ?
    5. 5. Non-opioids Weak opioids +/- non-opioids Strong opioids Recovery Operation Treatment of Low Back Pain World of Misery Non-pharmacological methods
    6. 6. 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.
    7. 7. <ul><li>Targeted delivery of drugs. </li></ul><ul><li>Aims to correct the pathology </li></ul><ul><li>Blocking of nerve signals corrects neuropathy. </li></ul><ul><li>Steroids, Neurolytics, Local anaesthetics </li></ul><ul><li>Adhesinolysis, Vertebroplasty, Kypho-plasty </li></ul><ul><li>LA, Ozone Neurolytics, Radiofrequency ablation, Chemical & Electrical Neuromodulation </li></ul>IPM IPM are group of procedures with different mechanism of actions
    8. 8. Scope/ indications <ul><li>Head & Neck </li></ul><ul><ul><li>Headache: nerve blocks, PNS, </li></ul></ul><ul><ul><li>Gasserian ganglion block -trigeminal neuralgia </li></ul></ul><ul><ul><li>Cervical epidural , facet, RF, stellate gn block </li></ul></ul><ul><li>Thorax </li></ul><ul><ul><li>Cryo Intercostal nerves, Facet, RF </li></ul></ul><ul><li>Pelvic pain: hypogastric plexus block </li></ul><ul><li>Abdominal Cancer pain: celiac plexus </li></ul><ul><li>Low Back Pain………… </li></ul>
    9. 9. Structures responsible for LBP
    10. 10. Major Causes of Low Back Pain <ul><li>Facet joint arthropathy 15-45% </li></ul><ul><li>Interval disc disruption 25-40% </li></ul><ul><li>Sacro-Iliac joint arthropathy 15-30% </li></ul><ul><li>Disc prolapse/ herniated disc/ slipped disc-2-5% </li></ul><ul><li>Chronic Regional Pain Syndrome 2-8% </li></ul><ul><li>Failed Back Surgery Syndrome 1% </li></ul><ul><li>Pyriform syndrome </li></ul>www. pain india.net
    11. 11. Low Back Pain: Red Flags <ul><li>Possible fracture </li></ul><ul><li>Possible tumor or infection. </li></ul><ul><li>Bladder or Bowel dysfunction. </li></ul><ul><li>Severe or progressive neurologic dysfunction in the legs. </li></ul><ul><li>Major motor weakness in quadriceps, plantar flexors, evertors, and dorsiflexors. </li></ul>
    12. 12. Facet Joint Interventions <ul><li>Intra-articular injections </li></ul><ul><li>Medial branch block </li></ul><ul><li>Radiofrequency ablation </li></ul><ul><li>Facet joint ( zygapophysial) </li></ul><ul><li>arthropathy 15-45% </li></ul>
    13. 13. Facet Joint Interventions Lumbar “ Scottie Dog” View
    14. 14. 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
    15. 15. Facet Joint Interventions Lumbar - RF L5 L4 S1
    16. 16. Radiofrequency Ablation (RF)
    17. 17. LBP ; Disc (Disc Cause LBP 25% to 45%)
    18. 18. Disc procedures <ul><li>Epidural Steroid Inj. </li></ul><ul><li>Selective Nerve root / transforaminal Inj. </li></ul><ul><li>Discectomy </li></ul><ul><li>Ozone nucleolysis </li></ul><ul><li>RF procedures (Intradiscal Electrothermal Annuloplasty (IDEA), or IDET </li></ul>www. pain india.net
    19. 19. Epidural Approaches <ul><li>Decrease phospholipase A2 and complements </li></ul><ul><li>Histamine Antagonist </li></ul><ul><li>Anti-inflammatory </li></ul><ul><li>Local Anaesthetic </li></ul><ul><li>Volume effect </li></ul><ul><li>Non-specific </li></ul>Midline Interlaminar L5-S1
    20. 20. Transforaminal Approach
    21. 22. Transforaminal Approach
    22. 23. Ozone Nucleolysis <ul><li>It breaks down proteo-glycan bridges in the nucleus pulposus. </li></ul><ul><li>As a result disc shrinks and mummified and there is decompression of nerve roots. </li></ul><ul><li>It has high success rate(88%). </li></ul><ul><li>It is less invasive. </li></ul><ul><li>Fewer chances of recurrences. </li></ul><ul><li>Remarkably fewer side effects. </li></ul>
    23. 24. Intradiscal Procedures <ul><li>Intradiscal coagulation with conventional RF </li></ul><ul><li>Intradiscal electromagnetic field (with Pulsed RF) </li></ul><ul><li>Posterior annuloplasty (Coblation) </li></ul><ul><li>IDET (Intradiscal electro-thermal coagulation & </li></ul>
    24. 25. I-DET
    25. 26. 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.
    26. 27. Vertebroplasty
    27. 28. POST LAMINECTOMY SYNDROME <ul><li>Mechanical lesion </li></ul><ul><li>* Spinal stenosis </li></ul><ul><li>* Recurrent disk </li></ul><ul><li>* Spinal instability </li></ul><ul><li>Often can be corrected with additional surgical procedures </li></ul><ul><li>Non mechanical lesion </li></ul><ul><li>*Epidural fibrosis </li></ul><ul><li>* Arachnoiditis </li></ul><ul><li>* Neuropathic pain </li></ul><ul><li>*Psychosomatic pain </li></ul><ul><li>Not amenable to surgical treatment </li></ul>
    28. 29. POST LAMINECTOMY SYNDROME <ul><li>Surgery (success rate 20%-30%) </li></ul><ul><li>Interventions Management of FBSS </li></ul><ul><li>* Epidural adhesinolysis: Fluoroscopic hydrodynamic process using corticosteroids, hypertonic saline, L.A., hyaluronidase. </li></ul>
    29. 30. Epidural Adhesinolysis Normal Filling defect in FBSS www. pain india.net
    30. 31. POST LAMINECTOMY SYNDROME <ul><li>Epiduroscopy </li></ul>
    31. 32. POST LAMINECTOMY SYNDROME <ul><li>Advanced pain modulation therapies </li></ul><ul><li>Spinal cord stimulation (SCS); Chronic neuropathic pain of a non-structural nature * </li></ul><ul><li>Intrathecal drug delivery system; persistent nociceptive pain who had structurally successful surgery. </li></ul><ul><li>(spinal administration of opioids via implantable continuous drug </li></ul>Spinal cord stimulator Intrathecal pump
    32. 33. Evidence based practices Outcome studies <ul><li>Even in patients of PIVD with neuro-deficits (numbness & weakness) there is equal chance of cure between surgical and non-surgical managements. </li></ul><ul><li>83% of patients for whom urgent surgery was recommended could avoid surgery & still achieved good/excellent outcome. </li></ul><ul><li>A large scale English study showed that 86% good outcome with non-surgical treatment. </li></ul>www. pain india.net
    33. 45. Results & Gapes <ul><li>50% relief in 50% of the patient for reasonable duration (3wks 14 months) </li></ul><ul><li>Our results </li></ul><ul><li>Gapes: </li></ul><ul><ul><li>Vertebroplasty and Discectomy kits </li></ul></ul><ul><ul><li>RF </li></ul></ul><ul><li>Future…… </li></ul>
    34. 46. Thanks Thank you