Lawrence Jay Epstein, MD Associate Director, Division of Pain Management.
 
<ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul>
<ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul><ul><li>Axial vs. Radiating </li></ul>
<ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul><ul><li>Axial vs. Radiating </li></ul><ul><li>Discogenic vs. Spondyliti...
<ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul><ul><li>Axial vs. Radiating </li></ul><ul><li>Discogenic vs. Spondyliti...
<ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul><ul><li>Axial vs. Radiating </li></ul><ul><li>Discogenic vs. Spondyliti...
<ul><li>Myelopathic signs </li></ul><ul><ul><li>Hyper-reflexia </li></ul></ul><ul><ul><li>Clonus </li></ul></ul><ul><li>Fe...
<ul><li>NSAID’s </li></ul><ul><ul><li>Oral </li></ul></ul><ul><ul><li>Topical </li></ul></ul><ul><li>Muscle Relaxants </li...
 
<ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Spondylitic </li></ul></ul>
<ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Spondylitic (Pain on extension, brushing teeth, shaving, brushing...
<ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Discogenic </li></ul></ul>
<ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Discogenic (Worst with flexion) </li></ul></ul><ul><ul><ul><li>Ph...
<ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Discogenic (Worst with flexion) </li></ul></ul><ul><ul><ul><li>Di...
<ul><li>Referred vs. Radicular? </li></ul>
<ul><li>Referred </li></ul>
<ul><li>Referred </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><ul><li>Not Dermatomal. </li></ul></ul></ul><ul><ul>...
<ul><li>Radicular </li></ul>
<ul><li>Radicular </li></ul><ul><ul><li>History: </li></ul></ul><ul><ul><ul><li>Dermatomal </li></ul></ul></ul><ul><ul><ul...
<ul><li>Radicular-Spondylitic </li></ul><ul><ul><li>Epidural (Trans-foraminal or directed catheter?) </li></ul></ul><ul><u...
<ul><li>Radicular-Discogenic </li></ul><ul><ul><li>Epidural (Trans-foraminal) </li></ul></ul><ul><ul><li>Pharmacological <...
 
 
 
AP fluoroscopic image of a cervical interlaminar epidural steroid injection with a catheter threaded to C6/7 in a patient ...
AP fluoroscopic image of a cervical interlaminar epidural steroid injection with a catheter threaded to C5/6 in a patient ...
AP fluoroscopic image of a right C5/6 transforaminal epidural steroid injection.
AP fluoroscopic image of a right C5/6 transforaminal epidural steroid injection. Note that vascular uptake not seen on the...
 
 
 
 
 
 
 
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Management of neck pain

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  • How can we stratify so that we can follow an algorythm?
  • Real answer is an integration of all these.
  • Rule #1 LOOK FOR BADNESS!!
  • All Question Marks
  • Note that pathological classification (is; Spondylitic vs. Discogenic) does not help in distinguishing as you can have radicular pain from spondylitic disease (Foraminal Stenosis)
  • Management of neck pain

    1. 1. Lawrence Jay Epstein, MD Associate Director, Division of Pain Management.
    2. 3. <ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul>
    3. 4. <ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul><ul><li>Axial vs. Radiating </li></ul>
    4. 5. <ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul><ul><li>Axial vs. Radiating </li></ul><ul><li>Discogenic vs. Spondylitic </li></ul>
    5. 6. <ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul><ul><li>Axial vs. Radiating </li></ul><ul><li>Discogenic vs. Spondylitic </li></ul><ul><li>Inflammatory vs. Mechanical </li></ul>
    6. 7. <ul><li>Acute vs. “Sub-Acute” or Chronic </li></ul><ul><li>Axial vs. Radiating </li></ul><ul><li>Discogenic vs. Spondylitic </li></ul><ul><li>Inflammatory vs. Mechanical </li></ul><ul><li>Stable vs. Progressive </li></ul>
    7. 8. <ul><li>Myelopathic signs </li></ul><ul><ul><li>Hyper-reflexia </li></ul></ul><ul><ul><li>Clonus </li></ul></ul><ul><li>Fever </li></ul><ul><li>History of Malignancy </li></ul><ul><li>Lehrmitt’s Sign </li></ul>
    8. 9. <ul><li>NSAID’s </li></ul><ul><ul><li>Oral </li></ul></ul><ul><ul><li>Topical </li></ul></ul><ul><li>Muscle Relaxants </li></ul><ul><li>Physical Therapy </li></ul><ul><ul><li>“ Modalities” </li></ul></ul><ul><ul><li>R.O.M./Stretching </li></ul></ul><ul><li>Analgesics </li></ul><ul><li>Intervention? </li></ul>
    9. 11. <ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Spondylitic </li></ul></ul>
    10. 12. <ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Spondylitic (Pain on extension, brushing teeth, shaving, brushing hair). Worse in AM or after inactivity.) </li></ul></ul><ul><ul><ul><li>Physical Therapy – *Posture </li></ul></ul></ul><ul><ul><ul><li>Facet Block </li></ul></ul></ul><ul><ul><ul><ul><li>Intra-articular </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Medial Branch Block </li></ul></ul></ul></ul><ul><ul><ul><li>R.F.T.C. </li></ul></ul></ul>
    11. 13. <ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Discogenic </li></ul></ul>
    12. 14. <ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Discogenic (Worst with flexion) </li></ul></ul><ul><ul><ul><li>Physical Therapy </li></ul></ul></ul><ul><ul><ul><li>Epidural Steroids (Approach?) </li></ul></ul></ul><ul><ul><ul><ul><li>Trans-Laminar </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Trans-Foraminal (Contraindicated?) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Catherization </li></ul></ul></ul></ul><ul><ul><ul><li>Facet Block (Medial Branch) </li></ul></ul></ul>
    13. 15. <ul><li>Spondylitic vs. Discogenic </li></ul><ul><ul><li>Discogenic (Worst with flexion) </li></ul></ul><ul><ul><ul><li>Discography “+” </li></ul></ul></ul><ul><ul><ul><ul><li>TENS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>PT/Analgesics/Opiates? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Percutaneous Disc Decompression? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cervical Fusion? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Peripheral (Sub-cutaneous) Stimulation? </li></ul></ul></ul></ul>
    14. 16. <ul><li>Referred vs. Radicular? </li></ul>
    15. 17. <ul><li>Referred </li></ul>
    16. 18. <ul><li>Referred </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><ul><li>Not Dermatomal. </li></ul></ul></ul><ul><ul><ul><li>“ Ache” </li></ul></ul></ul><ul><ul><ul><li>Pain seems to “move around”. </li></ul></ul></ul><ul><ul><ul><li>Rarely radiation reaches elbow. </li></ul></ul></ul><ul><ul><li>Physical </li></ul></ul><ul><ul><ul><li>“ -” Stretch Signs (Spurling’s?) </li></ul></ul></ul><ul><ul><ul><li>No Neurological Deficit </li></ul></ul></ul>
    17. 19. <ul><li>Radicular </li></ul>
    18. 20. <ul><li>Radicular </li></ul><ul><ul><li>History: </li></ul></ul><ul><ul><ul><li>Dermatomal </li></ul></ul></ul><ul><ul><ul><li>Extends past elbow </li></ul></ul></ul><ul><ul><ul><li>“ Electric Shocks” </li></ul></ul></ul><ul><ul><ul><li>Numbness/Weakness </li></ul></ul></ul><ul><ul><li>Physical </li></ul></ul><ul><ul><ul><li>Neurological Deficit </li></ul></ul></ul>
    19. 21. <ul><li>Radicular-Spondylitic </li></ul><ul><ul><li>Epidural (Trans-foraminal or directed catheter?) </li></ul></ul><ul><ul><li>Pharmacological </li></ul></ul><ul><ul><ul><li>Pre-gabalin/Gabapentin </li></ul></ul></ul><ul><ul><ul><li>Amitriptyline/Nortriptyline </li></ul></ul></ul><ul><ul><ul><li>Other Adjuncts (Benzodiazepines, Cymbalta/Savella, baclofen, etc) </li></ul></ul></ul><ul><ul><li>Decompression </li></ul></ul><ul><ul><li>Dorsal Column Stimulation </li></ul></ul>
    20. 22. <ul><li>Radicular-Discogenic </li></ul><ul><ul><li>Epidural (Trans-foraminal) </li></ul></ul><ul><ul><li>Pharmacological </li></ul></ul><ul><ul><ul><li>Pre-gabalin/Gabapentin </li></ul></ul></ul><ul><ul><ul><li>Amitriptyline/Nortriptyline </li></ul></ul></ul><ul><ul><ul><li>Other Adjuncts (Benzodiazepines, Cymbalta/Savella, baclofen, etc) </li></ul></ul></ul><ul><ul><li>Decompression (Percutaneous vs. Open) </li></ul></ul><ul><ul><li>Dorsal Column Stimulation </li></ul></ul>
    21. 26. AP fluoroscopic image of a cervical interlaminar epidural steroid injection with a catheter threaded to C6/7 in a patient with a left C7 radiculopathy. Note needle entry at T2/3.
    22. 27. AP fluoroscopic image of a cervical interlaminar epidural steroid injection with a catheter threaded to C5/6 in a patient with a right C6 radiculopathy. Note needle entry at T1/2.
    23. 28. AP fluoroscopic image of a right C5/6 transforaminal epidural steroid injection.
    24. 29. AP fluoroscopic image of a right C5/6 transforaminal epidural steroid injection. Note that vascular uptake not seen on the previous image is apparent with contrast injection under live fluoroscopy.

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