Spinal Injections

29,504 views

Published on

Interventional Spinal INjections in Third World

Published in: Health & Medicine
2 Comments
10 Likes
Statistics
Notes
No Downloads
Views
Total views
29,504
On SlideShare
0
From Embeds
0
Number of Embeds
30
Actions
Shares
0
Downloads
0
Comments
2
Likes
10
Embeds 0
No embeds

No notes for slide
  • <number><number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • Spinal Injections

    1. 1. Current Spinal Interventional Procedures in Chronic Pain Management Segun T. Dawodu, MD, LL.B, MBA Medical Director, PMREHAB PAIN & SPORTS MEDICINE ASSOCIATES, BOWIE, MD 20716, USA E-mail: segun@dawodu.com www.pmrehab.com
    2. 2. What is Percutaneous Spinal Intervention?  Use of minimal invasive methodology to access the spine  Often using Needles with Fluoroscopic guidance  Allows Medications like Local anesthetics and Steroids to be injected  Allows access to other spine structures
    3. 3. Training Required To be a Pain Spinal Interventionist in the USA  Residency Training in either Anesthesiology, Physical Medicine/Rehabilitation or Neurology  Fellowship Training in Pain Medicine  Board Certification in Primary Specialty  Board Certification in Pain Medicine
    4. 4. Basic Facility and Equipment Requirements For Interventional Spine Procedures  Ambulatory Surgical Center or Hospital  Operating Rooms/Recovery Rooms as day cases  C-arm Fluoroscopy  Fluoroscopy Table  Theatre Nurses  Anesthetists/Anesthesiologists  Electro Thermal Machine
    5. 5. Ambulatory Surgical Center
    6. 6. C-arm Fluoroscope
    7. 7. Fluoroscopic Surgical Table
    8. 8. Electro Thermal Machine Radionics RFA Machine
    9. 9. Types of Spinal Interventions -1  Caudal Epidural  Translaminar Epidural  Transforaminal Epidural  Selective Nerve Root Block  Facet Medial Branch Nerve Block  Radiofrequency Ablation of Nerves  Sacro-iliac Joint injection  Discography  Sympathetic Block
    10. 10. Types of Spinal Interventions -2  Spinal Epidural Endoscopy  Selective Endoscopic Discectomy  Peridural Adhesiolysis (Racz Procedure)  Percutaneous Disc Decompression  Vertebroplasty/Kyphoplasty  Nucleoplasty  IntraDiscal Electro Thermal Annuloplasty (IDET)  Prolotherapy  Spinal Cord Stimulator/Spinal Pump Implant  Others e.g Celiac Plexus block, Trigeminal n. block
    11. 11. Caudal Epidural Injections - 1  Injection of Medications through the Sacral hiatus into the Epidural space
    12. 12. Caudal Epidural Injections - 2  Indicated in Lower Lumbosacral Nerve Root irritations e.g. L5/S1 Disc herniation  Ideally done under Fluoroscopy guidance  Dye e.g Omnipaque is injected to confirm positioning in the epidural space  Local anesthetic + Steroid injected into the Epidural space through the Sacral Hiatus approach  Expected Immediate Pain Relieve  Patient observed in the Recovery room and discharged home same day when stable.
    13. 13. Translaminar Epidural Injection  Similar to Caudal Epidural BUT going between the laminars  C7 position for Cervical spine and btw L2/L3 for Lumbar Spine  Pre and Post care as for Caudal Epidural
    14. 14. Transforaminal Epidural Injection  Access to the spinal cord and Nerve roots through the Transforaminal space  Similar to Translaminar approach in terms of medications injected
    15. 15. Selective Nerve Root Block  Similar to Transforaminal epidural injection  Dye injected defines the nerve root before medication is injected  More of a diagnostic indication to define level of radicular pain.  A positive finding helps in defining level for a subsequent Transforaminal epidural injection
    16. 16. Facet Medial Branch Nerve Block  Facet joint injection becoming obsolete  Facet medial branch nerve block more acceptable since advent of RFA  Needle placed at the junction of the Superior articular process & transverse process
    17. 17. Radiofrequency Ablation of Nerves  Radiofrequency Ablation (RFA) uses electrical impulses to interrupt nerve conduction on a semi-permanent basis.  Lesioning of C-fibers component of the nerves.  The fibers recover after 6-18 months.  Used after diagnostic Facet Medial Branch Block is Positive on the Facet Medial Branch Nerve, and ditto for the Selective Nerve Roots.  Lesioning at either 42 or 80 degrees centigrade for 90-120 seconds, 42 using a pulsed mode, 80 using a regular mode  Lesioning at 42 degrees centigrade using the pulsed mode is now highly recommended
    18. 18. Sacro-iliac Joint injection
    19. 19. Sacro-iliac Joint injection  Under Fluoroscopic Guidance.  Spinal Needle inserted into the Posterior-Inferior aspect of the Joint  Dye injected to confirm placement  Steroid + Local anesthetic injected  New procedures of RFA of nerve roots L5,S1 and S2 for SIJ pain now emerging after a post SIJ injection relieve
    20. 20. Sacro-iliac Joint injection
    21. 21. Discography  Contrast injection into the disc to confirm or deny the disc as source of pain  Done under fluoroscopic guidance, with patient sedated and dye injected under different pressure  Patient asked if pain is produced similar to pain experienced normally.  Prelude to an IDET, Annuloplasty, Nucleoplasty or Discectomy  Necessary as CT Scan and MRI only show structure without confirming if a disc is actually the cause of pain  Post-procedure plain radiograph or CT scan is done to document lesion.
    22. 22. Discography - 1
    23. 23. Discography - 2
    24. 24. Sympathetic Block  Entails injecting local anesthetic around the sympathetic nerves in cervical(Stellate Ganglion and Lumbar areas.  Mostly diagnostic for Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy), Neuropathic Pain  Pain relieve from diagnostic block qualifies a patient for a either a repeat block or an RFA of the nerves
    25. 25. Spinal Epidural Endoscopy - 1  Passage of a fiber-optic endoscope into the spinal canal  Direct visualization of the spinal canal, epidural space and related structures  Visualization of fibrosis of nerve roots, inflamed nerve roots, bulging disc etc  Main option for post-op adhesions and fibrosis from chronic inflammation  Passage through the sacral hiatus  Allows injection and infusion of medications
    26. 26. Spinal Epidural Endoscopy - A = Fiber-optic access port, B= Guide wire/instrumentation access port, C = Steering Mechanism D = Flexible tip with 2 working 1mm channels , E = Injection Port, F = Infusion port
    27. 27. Selective Endoscopic Discectomy  In treatment of annular tears and herniated discs  Not very commonly used  Placement of a wire and later the scope at 45 degrees into the disc using the seldinger technique.  Mechanical dissection of posterior 1/3rd of the disc through the scope  Dissection of adhesions around the nerve roots could be done  Laser and Radiofrequency lesioning could also be performed
    28. 28. Peridural Adhesiolysis  Also called Racz Procedure  Being superseded by Epidural Endoscopy  Wire Catheter is passed through the Sacral Hiatus into the spinal canal  Lysis of adhesions around the nerve roots done through injection of hyaluronidase, saline  Local anesthetics and steroid can also be injected  May sometimes be used as an intermediate procedure before the Epidural endoscopy
    29. 29. Peridural Adhesiolysis - 2
    30. 30. Percutaneous Disc Decompression  Percutaneous removal of discs  A needle is introduced into the disc, a coblation probe is then introduced into the disc via the needle  Channels are created by heating the probe to 40-70ºC coagulating the tissue whivh are then removed on withdrawal of the probe
    31. 31. Vertebroplasty / Kyphoplasty  Vertebroplasty treats Pain from Collapsed Vertebra  “Cement” polymethyl methacrylate is injected into the center vertebral body  Kyphoplasty is similar to vertebroplasty except that a balloon is inserted and inflated to restore height prior to cement injection
    32. 32. Vertebroplasty / Kyphoplasty
    33. 33. Nucleoplasty  Another form of percutaneous disc decompression using the coblation technology Coblation – Removal of tissue as SpineWand is advanced / Coagulation – Thermal treatment of tissue as SpineWand is withdrawn
    34. 34. IntraDiscal Electro Thermal Annuloplasty  Also called IDET.  Heating element is introduced into the disc and modify the protein wall of the disc reducing the amount of disc material irritating the nerve  A needle is passed into the disc under flouroscopy.  The heating wire is then passed into the disc through the needle and curved inside the disc around the nucleus pulposus until it lies posterior to the Annulus Fibrosus, usually where the tear is  Using Radiofrequency, the wire is heated to 90ºC for about 15 minutes
    35. 35. IntraDiscal Electro Thermal Annuloplasty
    36. 36. Prolotherapy  “Prolo” is from proliferation  Prolotherapy is the use of hypertonic dextrose solution into ligaments/tendons where they are weak causing inflammation with associated increased blood flow which is followed by repair and proliferation of the tissue  It is easily done in the Office for other joints  Requires fluoroscopy for spinal ligament injection  It is a low tech procedure
    37. 37. Spinal Cord Stimulator  Insertion of electrodes into the spinal canal close to nerve roots or spinal cord  Electric current then stimulates the dorsal column disrupting the path for pain transmission to the brain (gate theory)  It is an option of last resort after failures of all other treatments. It is more invasive than other spinal interventions mentioned earlier  The spinal cord stimulator consists of 3 parts: power source, electrode leads and external controller  It is like placing a TENS unit in the spinal cord  The power source is implanted in the abdominal wall
    38. 38. Spinal Cord Stimulator
    39. 39. Spinal Pump Implant  Procedure similar to Spinal cord stimulator insertion  Becoming obsolete for treating chronic pain because of high complication rate  Now indicated for pain control in a terminally ill patient  Placement of morphine in the intrathecal space via a reservoir(pump)  Initial trial with direct intrathecal injection before final pump placement  Psychological screening also required before placement  Pump/reservoir placed in the abdominal wall, the tube is tunneled into the intrathecal space. 1mg of IT morphine = 75mg oral morphine. Most people require 1-4mg IT/day
    40. 40. Spinal Pump Implant
    41. 41. Other Nerve Blocks
    42. 42. Spinal Interventions in Developing Countries  Cost-effectiveness of the procedures compared with surgery  Problems with getting genuine medications into the country  Lack of adequate facilities and equipments  Lack of training and formal education in the subspecialty of pain medicine  Problems of placing procedures in Hospitals as compared with ambulatory surgical center.  Use of “hired” or “shared” services in ambulatory surgical center – an idea that does not exist in most developing countries  Trained Radiological Technicians to assist in fluoroscopy use  Trained Nurses for recovery room monitor prior to discharge home
    43. 43. Spinal Interventions in Developing Countries DO ABLE 2. Caudal Epidural 3. Facet Median Branch Block 4. Transforaminal and Translaminar Epidural 5. Selective Nerve Root Blocks 6. Radiofrequency ablation of nerves 7. Sympathetic Nerves’ Block 8. Sacro-iliac Joint Injection 9. Discography NOT DO ABLE All others due to exorbitant cost and manpower/training issues
    44. 44. Conclusion  Future of Chronic spinal pain lies in minimal invasive spinal procedures  Most of the procedures are day cases  Training of Personnel and Certification need to be pursued and encouraged  Basic equipments needed including Fluoroscope and Radiofrequency machine are relative cheap for second hands  The cost cutting in getting the machines is achieved by the cut in surgeries and prolonged stay in hospital  Spinal interventions should be the second option in pain management after failure of medications and before surgery in line with the dictum of Conservative Management before surgery
    45. 45. END Thank You Segun T. Dawodu, MD, LL.B, MBA E-mail: segun@dawodu.com

    ×