Interventional approach to back pain dr surange

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Interventional approach to back pain dr surange

  1. 1. Dr (Maj) Pankaj N Surange MBBS, MD (Anesthesiology), FIPP (Hungary) Interventional Pain and Spine SpecialistSecretary, World Institute of Pain, India Chapter www.ipscindia.com
  2. 2. Interventional Pain management Interventional Pain management Interventions are Minimally Invasive, Non Surgical and Target Specific procedures to Diagnose and to treat Various painful conditions It fills the gap between pharmacologic management of pain & more invasive operative procedure
  3. 3. Important facts about pain management as the Speciality Recognised as a 34th speciality in USA: American society of Interventional pain physician In USA, The Department of Health and Human Services Centers for Medicare and Medicaid Services issued a memo March 4, 2005, including Interventional Pain Management specialists on the list of clinical specialties to be included in carrier advisory committees. Pain as fifth vital sign Pain relief a human right – WHO (world health organization) "Pain relief should be a human right, whether people are suffering from cancer, HIV/AIDS or any other painful condition,“
  4. 4. Intenational Association for study of Pain- 1973 World Institute of Pain-1993 Fellowship -2001
  5. 5. Semmelweis University, Budapest(Hungary) FIPP-2009
  6. 6. CASE 1• 36 Years, Executive• Back pain with radiation to Left leg for 4 months.• Lost his job.• Progressively increasing and association with paresthesia.
  7. 7. Case 1-Contained Disc Herniation
  8. 8. Management : Disc Herniation Percutaneous Ozonucleolysis + Transforaminal L5 and S1 Needle is inserted into the centre Under fluoroscopic Guidance of the Disc and ozone is Injected. Correct level of the prolapsed . Pain relief starts usually within disc is identified one week and ozone takes 3-4 weeks for its complete effect
  9. 9. Management : Disc Herniation Percutaneous disc decompression Minimally invasive procedure using small needle and probe to remove disc material of prolapsed disc ,releasing pressure on nerves and relieving pain in most of the patients of prolapsed/ bulging / slipped disc
  10. 10. Management : Case 1 Percutaneous Disc Decompression Rotating tip removes small portion of disc material. Because only enough of the disc is removed to reduce pressure inside the disc, the spine remains stable. Insertion site covered with bandage. Recovery is fast as unlike surgical decompression no bone or muscle is cut. 2-3 days of bed rest and may return to normal activity within one week.
  11. 11. Management : Case 1 Nucleotomy
  12. 12. Case 2• 42 Yrs/ Male• Back pain X 2 yrs• No h/o radiation to legs• Aggravating factors • Sitting > 40 min • Driving • Forward bending
  13. 13. Case 2- Discogenic Pain
  14. 14. Discogenic Pain
  15. 15. Management ;Case 2• Intradiscal Ozone By inhibiting inflammatory nociceptors
  16. 16. Management :Discogenic Pain Intradiscal Electrotherapy (IDET)
  17. 17. Management :Discogenic Pain Biculoplasty-
  18. 18. Facet Arthropathy secondaryMRI to Disc degeneration • Disc bears 80% of weight • Facet joints bears 20 % of weight A change in the intervertebral disc produces Change in the whole motion segment
  19. 19. Facet Arthropathy• Low back pain- unilateral or bilateral• Tenderness over facet joints• Pain is deep, dull aching, difficult to localize• Referred to the buttocks, groin, hip, or posterior and lateral thigh.• Pain is more prominent in the morning and with inactivity• May aggravate on extension after forward flexion
  20. 20. Management- Facet Arthropathy Inflammatory Type Degenerative type
  21. 21. Intra-articular Steroid
  22. 22. RF Ablation Median Branch
  23. 23. Case 3• 56 yrs /Female• Severe radicular pain in Rt Leg• H/o frequent back pains• Sensory loss in L5 Distribution and EHL- 4/5.• Known case of Rheumatoid Arthritis, Ucontrolled DM, CAD, Interstitial Lung disease.
  24. 24. Intraspinal Synovial Cyst
  25. 25. Management :Case 3• Percutaneous Transforaminal Cyst Aspiration
  26. 26. Case 4• 70 Yrs male/ obese• Back pain Rt > lt• Radiation to rt thigh --- lat surf of rt leg• Tossing on chair• 1st Investigation ordered –MRI LS SPINE
  27. 27. MRI
  28. 28. Case 5Physical Examination Rt SI Joint Tenderness +++
  29. 29. Management- Case 4 S I Jnt Injection
  30. 30. Case 5• 35 Yrs/Female• Known case of CA Cervix• Metastasis• Sudden onset of severe pain mid back• No neurological deficit
  31. 31. Compression Fracture Vertebral body
  32. 32. Case 6– 45 Yrs Male, only earning member– Traumatic Fracture D12 Vertebra– Totally bed ridden, Urinary catheter, Ryles tube feed
  33. 33. Fracture D12 Vertebra
  34. 34. Vertebroplasty
  35. 35. Kyphoplasty
  36. 36. Case 6• 55 yrs• DM X 25 Yrs• Progressively increasing stiffness Lt Shoulder• Movements Painful• MRI –Joint capsule and Synovial Thickening
  37. 37. PRF-Suprascapular Nerve
  38. 38. Case -7• 38 yrs male• Low back pain radiating to both legs more on right side.• He had history of disc prolapse of L4-5 & L5-S1 and has undergone surgery 2 times before (laminectomy, discectomy & excision of scar).• Pain is increasing day by day.• Repeated investigations & visit to 16 consultants for last 4 years has taken away all faith from any form of medical treatment.• MRI-Epidural Fibrosis
  39. 39. Failed Back Syndrome (FBSS)• Epidural Adhenolysis
  40. 40. Resistant Case of FBSS
  41. 41. Post op Trigeminal Neuralgia – Pt presented after 2 years of Surgery – No improvement after surgery – It was idiopathic TGN•
  42. 42. RF Ablation –Trigeminal Nerve
  43. 43. Interventional Pain Procedures • Limitations • Contraindications • Complications • Not Alternative to Surgery
  44. 44. Welcome to ICIPM 2012, AIIMS, New Delhi www.icipm2012.com Dr (Maj) Pankaj N Surange MD, FIPP Organizing Secretary, ICIPM 2012 Secretary, World Institute of Pain, India Section
  45. 45. Thanks

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