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Back Pain

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non operative techniques for back pain management

non operative techniques for back pain management


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  • 1. Dr. Shiraz Munshi MBBS,DNB(fellow) Interventional Pain Specialist Sterling Hospital, HCG Medi-Surge Hospital, Ahmedabad Chronic Back Pain A More Effective Approach
  • 2. NO ONE should live or die in pain
  • 3. Precision Diagnosis and Treatment of Back Pain
  • 4. WHAT DO WE TREAT
    • Back and Neck Pain
    • Radiculopathy (pain originating in the neck or back, running down the arm or leg)
    • Prolapsed Intervertebral Disc
    • Spondylolisthesis / lysis
    • Spinal Stenosis
    • Post Laminectomy pain
    • Trigeminal Neuralgia
    • RSD—Reflex Sympathetic Dystrophy ( CRPS 1 or 2 )
    • Myofascial pain
    • Rib fractures
    • Headaches
    • Shingles/Herpes Zoster
    • Diabetic Neuropathy Pain
    • Vascular (ischemic) Pain
    • Any Chronic Pain Syndrome
  • 5. The Spinal Column
    • The human spinal column is the center of postural control.
    • It is built to provide stability and at the same time allow flexibility.
    • These two seemingly incompatible functions of support (inflexibility) and movement (flexibility) are at opposite ends of a spectrum of movement, and this fact is one reason the spine is so vulnerable to injury.
  • 6. Old School Concepts of Neck & Back Pain
    • A Physical Cause for the Pain Does Not Exist or Cannot Be Diagnosed in 70% of cases
    • Psychosocial Issues Predominate
    • Treatments are Expensive, Risky, and Ineffective
  • 7. New Concepts of Back & Neck Pain
    • A physical cause for the pain can be found and diagnosed in almost 70% of cases
    • If back and neck pain are ignored biopsychosocial issues will predominate
    • Treatment is generally effective and low risk. Cost is substantially less when compared to continued disability and/or surgery.
  • 8. Early Intervention
    • Odds for return to work after:
      • 6 months?
      • 1 year?
      • 2 year?
  • 9. Return to Work Odds
  • 10. Proper Treatment of Neck & Back Pain Must Begin With The Diagnosis
    • Of fundamental importance
    • Often skipped!
    • Difficult without appropriate tools and strategies
    • 70% of problems DO have a diagnosable physical cause
  • 11. “ It is clear from clinical experience and formal studies that when a patient presents with spinal pain there are no clinical features that permit the source of pain to be diagnosed. Even imaging studies do not provide a diagnosis. The appropriate investigations are the ones that answer the questions ( where does the pain come from )” Bogduk et al
  • 12. Precision Diagnosis of Neck & Back Pain
    • Use a combination of:
      • History
      • Physical Exam
      • Radiologic Findings
      • Diagnostic Injections
  • 13. Anatomy of Spinal Pain Potential Pain Generators
    • SOFT TISSUE
    • JOINTS
    • NERVE ROOTS
    • DISCS
  • 14. Lumbar Disk
  • 15. Annulus Nucleus
    • Proteoglycan A2
    • Binds water
    • Chemical / irritant
    • Leaks out if annulus breaks
    • Causes severe inflammation
  • 16.  
  • 17.  
  • 18. Diagnosis
    • MRI – look for HOT spot – T2 weighted Images
    • Provocation discogram
  • 19. Diskogram
  • 20.  
  • 21.  
  • 22. CONTRAST DISTRIBUTION [80] : (AS EVALUATED BY FLUOROSCOPY )     Disk has a complete radio fissure that allows injected fluid to escape. Can be in any stage of degeneration.   “ Ruptured” (R)   Degenerated disk with radio fissure leading to the outer edge of the annulus.   “ Fissured” (F)   Degenerated disk with fissures and clefts in the nucleus and inner annulus.   “ Irregular” (I)   Mature disk with nucleus starting to degenerate into fibrous lumps.   “ Lobular” (L)   No signs of degeneration, Soft white amorphous nucleus   “ Cotton Ball” (CB)   Stage of Disk Degeneration (C-arm View)   Discogram Type “ Ruptured” “ Fissured” “ Irregular” “ Lobular” “ Cotton Ball”
  • 23. Management
    • Transforaminal selective nerve injection
    • Intradiscal therapy
    • DeKompressor Discectomy
    • OZONE Discectomy
    • IDET
    • Laser Discectomy
  • 24. Nerve Root
  • 25.
    • Clinical Indications
    • Large disk herniations
    • spinal stenosis
    • tumor invasion of nerve root
    • vertibral fracture
    • post herpatic neuralgia
    • discogenic pain
    • segmental neuralgias
    • prognostic
    • predicting efficacy of neurolytic or
    • neurosurgical treatment
  • 26. Injection Technique
    • done with C-arm fluoroscopic device
    • Steroid
    • Reverses effect of inflammatory mediators
    • Stops inflammation cascade
    • Helps in healing annular tear
    • Stabilizes cell membrane
    • Delays pain impulse conduction
    • Gives pan/ inflammation free time for disc herniation to settle down by natural process (Natural history of disc disease)
  • 27. Injection Technique
  • 28. Injection Technique
  • 29.  
  • 30. L4 nerve Root
  • 31. L4 nerve Root
  • 32. L4 nerve Root
  • 33. L4 nerve Root
  • 34. Management
    • Transforaminal selective nerve injection
    • Intradiscal therapy
    • DeKompressor Discectomy
    • OZONE Discectomy
    • IDET
    • Laser Discectomy
  • 35.
    • Dekompressor
  • 36. Management
    • Transforaminal selective nerve injection
    • Intradiscal therapy
    • DeKompressor Discectomy
    • OZONE Discectomy
    • IDET
    • Laser Discectomy`
    • Nucleoplasty
  • 37.  
  • 38. DISC Nucleoplasty Plasma coblation technology decompresses the disc
  • 39. Failed Back surgery syndrome (Post laminectomy pain syndrome)
    • Adhesions – Racz adhesiolysis
    • Recurrent disc herniation at same or adjacent level – treat similarly as disc prolapse
    • Facet joint pain - Denervation
    • Neuropathic pain – LS block / SCS / Intrathecal pump
  • 40. ADVANCED TECHNIQUES
    • RAC’S ADHESIONOLYSIS
    • Failed Back Syndrome, Radiculopathies, LCS etc not responding to previous mentioned procedures
    • RACZ Catheter – special spring loaded catheter with blunt tip
  • 41. Failed Back surgery syndrome (Post laminectomy pain syndrome)
    • Adhesions – Racz adhesiolysis
    • Recurrent disc herniation at same or adjacent level – treat similarly as disc prolapse
    • Facet joint pain - Denervation
    • Neuropathic pain – LS block / SCS / Intrathecal morphine pump
    • Intractable pain – SCS / Intrathecal morphine pump
  • 42.
    • SPINAL CORD STIMULATION
    • INTRA-SPINAL MORPHINE PUMP IMPLANTATIONS
  • 43. Equipment
  • 44. Trial
  • 45. Trial
  • 46. Lead Placement
    • Upper extremity T1-2
    • Low Back Pain T8-10
    • Lower extremity T10-12
  • 47. Trial
  • 48. Locate the “sweet spot”
  • 49. Facet Joint
  • 50. FACET JOINTS SPINAL NERVES
  • 51.  
  • 52. Pathophysiology of Facet Syndrome
    • With chronic inflammation these joints can fill with fluid and distend leading to pain
    • This could also cause compression of nerve root in the neural foramen
    • Synovial cyst can also cause pressure on the nerve root as would facet hypertrophy and osteomyelitis
  • 53. Pathophysiology of Facet Syndrome
    • Intervertebral disk space narrowing can lead to subluxation of facet joint
    • Capsular irritation and local inflammation can cause reflex spasm of paraspinal muscles
  • 54. Incidence
    • 5-40% of patients with chronic back pain suffer from facet induced pain
  • 55. Diagnosis
    • History
    • Physical examination
    • Diagnostic block
  • 56. History
    • 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
  • 57. History
    • Occasionally radiates below the knee but not into the foot
    • Sudden onset of pain usually in association with twisting, bending, or rotatory movement
    • Increased pain on external and lateral bending
  • 58. History
    • Pain is more prominent in the morning and with inactivity
    • Maybe aggravated on extension after forward flexion
    • Not exacerbated with Valsalva’s maneuver
  • 59. Examination
    • Paralumbar tenderness localized over the facet joints
    • Associated muscle spasm
    • No neurologic findings
    • Pain-inhibited weakness
    • Straight leg raising is negative for nerve root irritation
  • 60. Diagnostic Joint Injection
    • Technique
      • With fluoroscopic guidance
      • Place the needle in the joint with fluoroscopic guidance
  • 61.  
  • 62.  
  • 63. Facet Joint Injections
  • 64. Needle Placement for Median Branch Block
  • 65. Needle Placement for Median Branch Block
  • 66. Diagnostic Block
    • Long acting LA – sensorcaine - 50% reduction in the pain for 4 hours is considered positive response
    • Procedure repeated with Lidocaine
    • 50% pain reduction is for 2 hours is considered positive
    • Radiofrequency ablation of median branch is recommended
  • 67. RADIOFREQUENCY GENERATOR MACHINE
  • 68.
    • Radiofrequency (RF) lesioning
    • Safe, proven means of treating chronic pain
    • Continuous radiofrequency current is used to heat a small volume of nerve tissue, thereby disrupting pain signals from that specific area
    • This procedure has a selective effect on nerve fibers, reducing pain in target areas, but leaving other sensory capabilities intact.
    • A procedure developed more than 30 years ago
  • 69. Lumbar Facet Medial Branch Block Needle position at junction of SAP and TP Medial branch of Dorsal ramus
  • 70. FACET JOINTS - RF DENERVATION PATIENTS SELECTION - FLOW CHART FACET JOINTS BLOCK ( diagnostic – prognostic ) Unsteady pain relief Lasting pain releif Facet joints block repetition Unsteady pain relief RF DENERVATION
  • 71. Sacroiliac Joint
  • 72. Sacral Iliac Joint Injection
    • History: fall, or high velocity trauma (MVA)
    • PE : pain over SI joint, Patrick’s test,
    • Radiology : not very useful
    • Diagnosis: Gold Standard is flouroscopic guided injection of SI joint using dye and lidocaine
    • Treatment: SI joint injection with lidocaine and steroid and physical therapy.
    • We add hylase also sometimes for better penetration of the drugs
  • 73. Diagnostic - Sacroiliac Joint - Intraarticular injection
  • 74. Sacral Iliac Joint Injection
  • 75.
    • More advanced techniques available
  • 76. Muscles Soft Tissue ---Trigger Points
  • 77. IN SUMMARY…..
  • 78. Chronic Neck & Back Pain The NEW Pathway
    • Injury.
    • Conservative care without improvement (2-4 weeks).
    • PAIN MEDICINE evaluation.
    • Appropriate diagnostic injections.
    • Appropriate therapeutic interventions.
    • Rehabilitation.
    • Radiological studies as necessary and/or surgical referral if diagnostic injections reveal surgically correctable pathology.
  • 79. THERAPEUTIC WINDOW OF OPPORTUNITY
  • 80. Expectations – Good quality of life
  • 81. Treatment continuum
  • 82.  
  • 83. Thank you for your attention! Are there any questions?
  • 84. NO ONE should live or die in pain