Presented by: Dr Brendan Moore – Pain Medicine Specialist Physician Dr Greg Cowderoy – Radiologist Event: GP Education Day - 2015

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

3. Identifying appropriate
procedures for your
patient

4. Degenera(ve
Lumbar
Back
Pain

5. Degenera(on
of
Lumbar
Spine
• Disc
degenera(on
+
narrowing
• Osteoporosis
• Facet
Joint
Arthri(s
• Spinal
and
Foraminal
stenosis
• Loss
of
Lumbar
concavity

6. Posterior
Elements
• Facet
Joints
frequently
implicated
in
pain
• Mechanical
back
pain
with
upper
leg
and
buFock
radia(on

7. Origins
of
lumbar
pain
• Degenera(ve
Discs
• Vertebral
fractures
• Spinal
/
Foraminal
Stenosis
• Disc
Bulge
/
Prolapse
• Facet
Joint
• Muscle
/
SoI
(ssue

8. Invasive
Treatment
Op(ons
• Surgery
• Facet
Joint
Injec(on
• Radiofrequency
medial
branch
abla(on
• Epidural
/
Caudal
steroid
• Vertebroplasty
• Coeliac
/
Lumbar
Sympathe(c
Plexus
Blocks
• Sacro-­‐iliac
Joint
injec(on

10. Identifying appropriate procedures for
your patient
Identifying appropriate procedures for
your patient

11. • Who
should
order
the
Pain
procedure
?

12. How persistent pain can become a problem
Adapted from: Nicholas, 2008.

13. • Who
should
order
the
Pain
procedure
?

14. • Who
should
order
the
Pain
procedure
?
• Mul(disciplinary
considera(on
in
assessment
• Part
of
a
comprehensive
management
plan
• Pa(ent
fully
informed
– Poten(al
benefits
– Limita(ons
– Expecta(ons
– What
happens
next
• Clear
follow
up
plan

16. Facet
Joint
Injec(on
• Primarily
diagnos(c
• 25G
Spinal
needle
• LA
+
Steroid
• Steroid
confers
possible
longer
term
benefit

17. Sacro-­‐iliac
Joint
Injec(on

18. Medial
Branch
Nerve
Abla(on
• Denerva(on
of
Medial
Branch
via
Radiofrequency
Neurotomy

19. Radiofrequency
Neurotomy
• AP
and
oblique
views
to
confirm
posi(on
• Test
s(mula(on;
2.0
Hertz,
0
to
2.0
v
to
test
for
motor
nerve
contact
• Lesion
85oC
x
90sec

20. Cervical
Radiofrequency
Neurotomy

21. Cervical
Radiofrequency
Neurotomy

22. Lumbar
Epidural
Injec(on
• 18
or
16
G
Toohey
needle
• LOR
to
air
(or
saline)
• Radio-­‐opaque
contrast
to
confirm
posi(on
• Px
for
nerve
root
irrita(on
and
assoc.
radicular
pain

23. Lumbar
Epidural
Injec(on

24. Caudal
Epidural
Injec(on

25. Coeliac
Plexus
Block

26. Coeliac
Plexus
Block

27. Procedures available at a pain clinic
• Epidural injections
• Facet joint injections
• Sacroiliac joint injections
• Medial branch blocks
• Radiofrequency nerve ablation

28. Appropriate conditions for interventional
pain procedures
• Aseptic conditions
• Appropriate analgesia
• Monitored sedation with
anaesthetist in attendance
• Image intensifying X-ray or
CT guidance

29. 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

30. 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

31. 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

32. Facet joint injection
• Diagnostic
• 25G spinal needle
• Local anaesthetic + steroid
• Steroid indicative of possible
long-term benefit

33. Sacroiliac joint injection
• Indicated with referred pain
• Pain referral pattern – area around and just caudal to the
posterior superior iliac spine
• Referred pain in the low back, buttocks, abdomen, groin or legs
• In some patients, S-1 joint injections can provide significant
pain relief

34. Sacroiliac joint injection
• Diagnostic
• 25G spinal needle
• Local anaesthetic + steroid
• Steroid indicative of possible
long-term benefit

35. Medial branch blocks
• Medial branch nerves are the very small nerve branches that
controls sensation of the facet joint
• Indicated in low back pain (unilateral or bilateral)
• Pain usually aggravated by extension of the spine
• Medial branch blocks are a diagnostic procedure
• Can provide temporary pain relief

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

37. 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

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

39. Cervical
radiofrequency
neurotomy
-­‐
lateral
view
Marker
shows
needle
at
C2/3
facet
joint

40. QUEENSLAND

41. Queensland
Rural and regional health services
• Department of Health website has a comprehensive list of Statewide
Community Health Services
• www.health.qld.gov.au
Health Contact Centre
• 13-HEALTH telephone triage and referral service
• 24 hours, 7 days per week
• Based on a partnership model with Smart Service Queensland and the
Queensland Government
• Responsible for the development and integration of existing or future health
care services which are / can be delivered through contact centre
management practices

42. Accessing allied health services in your local area
Australian Psychological Society (APS)
• Find a psychologist in your local area – internet search
• APS homepage>Community Information>Find a Psychologist
Australian Physiotherapy Association
• Find a physiotherapist in your local area
• http://apa.advsol.com.au/
The Australian Pain Society has a comprehensive directory of Pain
Specialists, Multidisciplinary Pain Clinics and Pain Management Centres
• www.apsoc.org.au/facility_directory.php

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