power point

12. 7persantine
(dipyridamole) Aggrenox
(dipyridamole/aspirin)
7daysAspirin or aspirin
containing medications:
(i.e., Excedrin, Equagesic,
synalogos-DC, BC
Powder)
7Herbals containing
ginger, ginko biloba, or
feverfew 7
3Non-steroidal anti-
inflammatory drugs: (i.e.,
ibuprofen, Naproxen,
Mobic, Arthrotec,
Relafen, Daypro and
Celebrex)
5Orgaran (damaparoid)6Coumadin (warfarin)
12 houresHeparin, Lovenox
(enoxaparin), Innohep
(tinzaparin), Fragmin
(dalteparin), Normiflo
(ardaparin)
14Ticlid (ticlopidine)
7daysVitamin E (greater than
400 IU)
10Plavix (clopidogrel)
2Pletal (cilostazol) and

14. Facet joint
Facet joints (zygapophyseal joints) are paired synovial joints formed by articulation of the inferior
articular process of one vertebra with the superior articular process of the subjacent one. They
allow the spine to move in flexion, extension, and rotation.
Innervated by the medial branch originating from the dorsal ramus of the spinal nerve
usually the pain of facet joint created in the upper back and thigh regions. Pain
frequently is also referred into the groin, buttocks, hip, or lateral and posterior thigh regions
(or a combination of these sites). Pain is often described as a “deep, dull ache” and may
be either unilateral or bilateral. On physical examination, there may frequently be
increased pain with extension, tenderness to palpation over the affected joints, and
normal findings on neurologic examination. Electrical stimulation of the medial branch
nerves has also assisted in identifying referral pain patterns

20. Epidural steroid injection ESI

21. ILESI
Lumbar interlaminar epidural steroid injections can be helpful in the
management of lumbar radicular symptoms. Lumbar interlaminar
epidural injections instill medication into the posterior epidural space
with variable spread into the anterior epidural space
Lumbar interlaminar epidural steroid injections can be performed for
lower extremity radicular symptoms recalcitrant to conservative
interventions including medications and physical therapy. With
severe limitation of function
injections should be limited to 3 in a 6-month period or 4 in a year.
These should ideally be spaced by at least 14 days to assess full
response and minimize adrenal suppression.

23. TFESI
Transforaminal epidural steroid injections (TFESI’s) can be very helpful
in the management of lumbar radicular symptoms. Transforaminal
epidural injections instill medication along the affected nerve root
and into the anterior epidural space at the site of inflammation.
Lumbar spinal stenosis (central or foraminal) and herniated nucleus
pulposus can induce nerve root inflammation
Inflammation of the nerve root induces neurophysiologic and
histologic change ,that can result in radicular symptoms
Corticosteroid reduces morphologic and functional nerve root
changes, and lidocaine decreases nerve root inflammation, while
increasing intraradicular blood flow

26. Causes of Pain after Failed Back Surgery
improper preoperative patient selection before back surgery. This is the most common cause of
failed back surgery syndrome. Surgeons look for an anatomic lesion in the spine that they can
correlate with a patients pain pattern. Some lesions are more reliable than others. For example,
degenerative disc disease is less commonly correlated with patients back pain than leg pain
from a disc herniation pinching a nerve root. There are other sources of pain that can mimic back
pathology such as piriformis syndrome,sacroiliac joint dysfunction and hip pathology (such as hip
osteoarthritis).
Recurrent disc herniation after spine surgery. This is another common cause of recurrent pain
Technical error during spine surgery. a fragment of herniated disc material missed, or a piece of
bone left adjacent to the nerve, incorrect operative levels chosen during surgical planning
preoperative nerve damage that does not heal after a decompressive surgery, or nerve damage
that occurs during the surgery)
Scar tissue considerations

27. Scar Tissue and Pain After Back Surgery
peridural adhesiolysis
The formation of scar tissue near the nerve root (also called epidural fibrosis) is a
common occurrence after back surgery
Typically, symptoms associated with epidural fibrosis (scar tissue around the nerve
root) appear at 6 to 12 weeks after back surgery. This is often preceded by an
initial period of pain relief, after which the patient slowly develops recurrent leg
pain or back pain
Adhesiolysis was developed as a means of removing epidural scarring leading
directly or indirectly to compression, inflammation, swelling, or a decreased
nutritional supply of nerve roots. Adhesiolysis utilizes a number of modalities in the
effort to break up epidural scarring, including the use of a wire-bound catheter
for mechanical adhesiolysis, placement of the catheter in the ventro-lateral
aspect of the epidural space at the site of the exiting nerve root, and the use of
high volumes of injectate, including local anesthetics and saline, either
hypertonic or isotonic, along with steroids.

31. Sacroiliac joint

32. Contraindication
Absolute
Bacterial infection: systemic or localized at injection site
Bleeding diathesis: due to anticoagulants or hematological disease
Relative
Allergy to injectants; steroid psychosis
Pregnancy
NSAIDs, aspirin, or other antiplatelet agents (e.g. Ticlid, Plavix, Coumadin,
Trental, Pletal, Heparin, Lovenox, Innohep, Fragmin, Normiflo, Persantine,
Aggrenox, Ginko Biloba, Orgaran, and Damaparoid)
Hyperglycemia, adrenal suppression, immune compromise, or congestive
heart failure

33. COMPLICATION OF INTERVENTIONAL PROCEDURE
Potential complications
• Infection (cellulitis, osteomyelitis with potential spread to include epidural abscess, discitis, meningitis, arachnoiditis,
sepsis)
• Bleeding
• Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia, vasovagal reaction)
• Respiratory (oversedation, central nervous system trauma)
• Urologic (urinary retention, incontinence)
• Neurologic injury (direct neural trauma, compression from hematoma or abscess, radicular or vertebral artery
trauma, arterial particulate injection, seizure)
• Adverse local anesthetic drug reaction (CNS and cardiovascular toxicity, restlessness, anxiety, incoherent speech,
light-headedness, perioral parethesias, blurred vision, tremors, drowsiness, seizures, cardiac arrest, excessive intrathecal
or epidural local anesthetic injection resulting in spinal block or leg weakness)
• Adverse steroid reaction (facial flushing, injection site hypopigmentation, subcutaneous fat atrophy, increased
appetite, fluid retention, gastritis, malaise, euphoria, insomnia, headache, immunosupression, aseptic meningitis,
arachnoiditis, congestive heart failure, increased intraocular pressures, adrenal insufficiency, steroid myopathy, mania,
hyperglycemia, hypertension, epidural lipomatosis, menstrual irregularity)
• Allergic reaction (to non-ionic contrast agent allergy, local anesthetic, corticosteroid, or latex causing urticaria,
laryngeal edema, bronchospasm, anaphylaxis)
Potential post-procedural complaints
• Vasovagal reaction (hypotension, bradycardia, nausea, pallor, diaphoresis, syncope)
• Pain (injection site, radicular, corticosteroid flare) • Headache (corticosteroids)

34. Management of Side effects
We generally advise the patients to use
diphenhydramine or other allergy medications at
night for flushing and insomnia. We also
recommend acetaminophen 500 mg every 6
hours as needed for headache and pain and
prochlorperazine orally 5 mg every 6 hours if
needed .

39. References
Bogduk N. Diagnostic nerve locks in chronic pain. Best Pract Res Clin
Anaesthesiol 2002;16:56578.
Hansen HC. McKenzie-Brown AM. Cohen SP. Swicegood JR. Colson JD.
Manchikanti L. Sacroiliac joint interventions: a systematic review.
[Review] [132 refs] [Journal Article. Review] Pain Physician. 10(1):165-84,
2007 Jan.
Botwin KP, Natalicchio J, Hanna A. Fluorscopic guided lumbar
interlaminar epidural injections: A prospective evaluation of
epidurography contrast patterns and anatomical review of the
epidural space. Pain Physician 2004;7:77-80.