Back Pain


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non operative techniques for back pain management

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Back Pain

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