Dr Brendan Moore

1. Interventional
Procedures in Chronic
Pain
Dr Brendan Moore
Specialist Pain Medicine Physician
Adjunct Associate Professor
University of Queensland

2. Degenerative Lumbar Back Pain

4. Origins of lumbar pain
• Degenerative Discs
• Vertebral fractures
• Spinal / Foraminal
Stenosis
• Disc Bulge / Prolapse
• Facet Joint
• Muscle / Soft tissue

5. Invasive Treatment Options
• Surgery
• Facet Joint Injection
• Radiofrequency medial branch ablation
• Epidural / Caudal steroid
• Vertebroplasty
• Coeliac / Lumbar Sympathetic Plexus Blocks
• Sacro-iliac Joint injection

6. Posterior Elements
• Facet Joints frequently implicated in pain
• Mechanical back pain with upper leg and buttock
radiation

8. Procedures
• Epidural injections
– Cervical, Thoracic, Lumbar, Caudal
• Facet joint injections
• Sacroiliac joint injections
• Medial branch blocks
• Radiofrequency nerve ablation

9. Epidural injections
• Most effective in the presence of nerve root
compression and spinal stenosis
• Increased efficacy if given in the first weeks of
the onset of pain
• Effects of the injection tend to be temporary (1
week to 1 year)
• Can be beneficial in providing relief for patients
during an episode of severe back pain
• Allows patients to progress in their rehabilitation

10. Lumbar epidural injection
• 18G or 16G Toohey
needle
• Radio-opaque contrast
to confirm position
• Injection and
distribution of local
anaesthetic and
steroid to nerve root

11. Lumbar Epidural Injection

12. Caudal Epidural Injection

13. Facet joint injections
• Back pain originating from facet joints
• Low back pain (unilateral or bilateral) and no
root tension signs or neurological deficits
• Pain usually being aggravated by extension of
the spine
• Facet joint injection may reduce inflammation
and provide pain relief
• Therapeutic goal and potential benefit
– Temporary relief from pain
– Patient may proceed into an appropriate exercise program

14. Facet Joint Injection
• Primarily diagnostic
• 25G Spinal needle
• LA + Steroid
• Steroid confers possible
longer term benefit

15. Sacro-iliac Joint Injection

16. Medial branch nerve ablation
• Diagnostic medial
branch blocks
• Local anaesthetic +
steroid
• Progress to
radiofrequency
ablation if diagnostic
block indicative of
long-term benefit

17. Medial Branch Nerve Ablation
• Denervation of Medial
Branch via
Radiofrequency
Neurotomy

18. Radiofrequency neurotomy
X-ray to confirm needle position – AP and oblique
views
Test stimulation – 2.0 Hz 0–2 volt to test for motor
nerve contact
Lesion 85°C for 90 seconds

19. Cervical radiofrequency neurotomy
Position for C2/3 and C3/4 facet joint
radiofrequency

20. Cervical Radiofrequency Neurotomy

21. Cervical radiofrequency neurotomy –
lateral view
Marker shows needle at C2/3 facet joint

24. Opioid prescribing:
dose limits and
considerations

25. Suggested maximum opioid dose
• Consult a Pain Medicine Specialist if higher doses
considered necessary
1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010
Drug Maximum dose for GP
prescription
Morphine 120mg daily
Oxycodone 80mg daily
Hydromorphone 24 mg daily
Methadone 40mg daily
Fentanyl transdermal patch 25 mcg/hr applied every 3 days
Buprenorphine transdermal patch 40 mcg/hr applied weekly
Tramadol 400 mg daily

26. Dose conversion
Morphine
equivalence to
Ratio
morphine
: named
opioid
Examples of equivalent doses
Codeine 1:6 Morphine 10 mg Codeine 60 mg
Oxycodone 1.5:1 Morphine 60 mg Oxycodone 40 mg
Hydromorphone 5:1 Morphine 60 mg Hydromorphone 12 mg
Tramadol 1:5 Morphine 10 mg Tramadol 50 mg
Fentanyl Morphine 90 mg Fentanyl 25 mcg/h
Buprenorphine 75:1 Morphine 9 mg Buprenorphine 5 mcg/h
Methadone 3:1 Morphine 60 mg Methadone 20 mg
1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010

27. FPM Opioid Calculator App
Free download