Dr. Shiraz Munshi discusses his approach to treating chronic back pain, which involves precision diagnosis through a combination of history, physical exam, imaging, and diagnostic injections to identify the specific source of pain in 70% of cases. This allows for targeted, minimally invasive treatments like nerve blocks, radiofrequency ablation, and spinal cord stimulation to effectively manage pain and improve outcomes like returning to work. The document outlines various potential sources of spinal pain and techniques for diagnosing and treating conditions of the discs, facet joints, sacroiliac joints, and nerves.

1. Dr. Shiraz Munshi MBBS,DNB(fellow) Interventional Pain Specialist Sterling Hospital, HCG Medi-Surge Hospital, Ahmedabad Chronic Back Pain A More Effective Approach

2. NO ONE should live or die in pain

3. Precision Diagnosis and Treatment of Back Pain

4. WHAT DO WE TREAT Back and Neck Pain Radiculopathy (pain originating in the neck or back, running down the arm or leg) Prolapsed Intervertebral Disc Spondylolisthesis / lysis Spinal Stenosis Post Laminectomy pain Trigeminal Neuralgia RSD—Reflex Sympathetic Dystrophy ( CRPS 1 or 2 ) Myofascial pain Rib fractures Headaches Shingles/Herpes Zoster Diabetic Neuropathy Pain Vascular (ischemic) Pain Any Chronic Pain Syndrome

5. The Spinal Column The human spinal column is the center of postural control. It is built to provide stability and at the same time allow flexibility. These two seemingly incompatible functions of support (inflexibility) and movement (flexibility) are at opposite ends of a spectrum of movement, and this fact is one reason the spine is so vulnerable to injury.

6. Old School Concepts of Neck & Back Pain A Physical Cause for the Pain Does Not Exist or Cannot Be Diagnosed in 70% of cases Psychosocial Issues Predominate Treatments are Expensive, Risky, and Ineffective

7. New Concepts of Back & Neck Pain A physical cause for the pain can be found and diagnosed in almost 70% of cases If back and neck pain are ignored biopsychosocial issues will predominate Treatment is generally effective and low risk. Cost is substantially less when compared to continued disability and/or surgery.

8. Early Intervention Odds for return to work after: 6 months? 1 year? 2 year?

9. Return to Work Odds

10. Proper Treatment of Neck & Back Pain Must Begin With The Diagnosis Of fundamental importance Often skipped! Difficult without appropriate tools and strategies 70% of problems DO have a diagnosable physical cause

11. “ It is clear from clinical experience and formal studies that when a patient presents with spinal pain there are no clinical features that permit the source of pain to be diagnosed. Even imaging studies do not provide a diagnosis. The appropriate investigations are the ones that answer the questions ( where does the pain come from )” Bogduk et al

12. Precision Diagnosis of Neck & Back Pain Use a combination of: History Physical Exam Radiologic Findings Diagnostic Injections

13. Anatomy of Spinal Pain Potential Pain Generators SOFT TISSUE JOINTS NERVE ROOTS DISCS

14. Lumbar Disk

15. Annulus Nucleus Proteoglycan A2 Binds water Chemical / irritant Leaks out if annulus breaks Causes severe inflammation

18. Diagnosis MRI – look for HOT spot – T2 weighted Images Provocation discogram

19. Diskogram

22. CONTRAST DISTRIBUTION [80] : (AS EVALUATED BY FLUOROSCOPY ) Disk has a complete radio fissure that allows injected fluid to escape. Can be in any stage of degeneration. “ Ruptured” (R) Degenerated disk with radio fissure leading to the outer edge of the annulus. “ Fissured” (F) Degenerated disk with fissures and clefts in the nucleus and inner annulus. “ Irregular” (I) Mature disk with nucleus starting to degenerate into fibrous lumps. “ Lobular” (L) No signs of degeneration, Soft white amorphous nucleus “ Cotton Ball” (CB) Stage of Disk Degeneration (C-arm View) Discogram Type “ Ruptured” “ Fissured” “ Irregular” “ Lobular” “ Cotton Ball”

23. Management Transforaminal selective nerve injection Intradiscal therapy DeKompressor Discectomy OZONE Discectomy IDET Laser Discectomy

24. Nerve Root

25. Clinical Indications Large disk herniations spinal stenosis tumor invasion of nerve root vertibral fracture post herpatic neuralgia discogenic pain segmental neuralgias prognostic predicting efficacy of neurolytic or neurosurgical treatment

26. Injection Technique done with C-arm fluoroscopic device Steroid Reverses effect of inflammatory mediators Stops inflammation cascade Helps in healing annular tear Stabilizes cell membrane Delays pain impulse conduction Gives pan/ inflammation free time for disc herniation to settle down by natural process (Natural history of disc disease)

27. Injection Technique

28. Injection Technique

30. L4 nerve Root

31. L4 nerve Root

32. L4 nerve Root

33. L4 nerve Root

34. Management Transforaminal selective nerve injection Intradiscal therapy DeKompressor Discectomy OZONE Discectomy IDET Laser Discectomy

35. Dekompressor

36. Management Transforaminal selective nerve injection Intradiscal therapy DeKompressor Discectomy OZONE Discectomy IDET Laser Discectomy` Nucleoplasty

38. DISC Nucleoplasty Plasma coblation technology decompresses the disc

39. Failed Back surgery syndrome (Post laminectomy pain syndrome) Adhesions – Racz adhesiolysis Recurrent disc herniation at same or adjacent level – treat similarly as disc prolapse Facet joint pain - Denervation Neuropathic pain – LS block / SCS / Intrathecal pump

40. ADVANCED TECHNIQUES RAC’S ADHESIONOLYSIS Failed Back Syndrome, Radiculopathies, LCS etc not responding to previous mentioned procedures RACZ Catheter – special spring loaded catheter with blunt tip

41. Failed Back surgery syndrome (Post laminectomy pain syndrome) Adhesions – Racz adhesiolysis Recurrent disc herniation at same or adjacent level – treat similarly as disc prolapse Facet joint pain - Denervation Neuropathic pain – LS block / SCS / Intrathecal morphine pump Intractable pain – SCS / Intrathecal morphine pump

42. SPINAL CORD STIMULATION INTRA-SPINAL MORPHINE PUMP IMPLANTATIONS

43. Equipment

44. Trial

45. Trial

46. Lead Placement Upper extremity T1-2 Low Back Pain T8-10 Lower extremity T10-12

47. Trial

48. Locate the “sweet spot”

49. Facet Joint

50. FACET JOINTS SPINAL NERVES

52. Pathophysiology of Facet Syndrome With chronic inflammation these joints can fill with fluid and distend leading to pain This could also cause compression of nerve root in the neural foramen Synovial cyst can also cause pressure on the nerve root as would facet hypertrophy and osteomyelitis

53. Pathophysiology of Facet Syndrome Intervertebral disk space narrowing can lead to subluxation of facet joint Capsular irritation and local inflammation can cause reflex spasm of paraspinal muscles

54. Incidence 5-40% of patients with chronic back pain suffer from facet induced pain

55. Diagnosis History Physical examination Diagnostic block

56. History 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

57. History Occasionally radiates below the knee but not into the foot Sudden onset of pain usually in association with twisting, bending, or rotatory movement Increased pain on external and lateral bending

58. History Pain is more prominent in the morning and with inactivity Maybe aggravated on extension after forward flexion Not exacerbated with Valsalva’s maneuver

59. Examination Paralumbar tenderness localized over the facet joints Associated muscle spasm No neurologic findings Pain-inhibited weakness Straight leg raising is negative for nerve root irritation

60. Diagnostic Joint Injection Technique With fluoroscopic guidance Place the needle in the joint with fluoroscopic guidance

63. Facet Joint Injections

64. Needle Placement for Median Branch Block

65. Needle Placement for Median Branch Block

66. Diagnostic Block Long acting LA – sensorcaine - 50% reduction in the pain for 4 hours is considered positive response Procedure repeated with Lidocaine 50% pain reduction is for 2 hours is considered positive Radiofrequency ablation of median branch is recommended

67. RADIOFREQUENCY GENERATOR MACHINE

68. Radiofrequency (RF) lesioning Safe, proven means of treating chronic pain Continuous radiofrequency current is used to heat a small volume of nerve tissue, thereby disrupting pain signals from that specific area This procedure has a selective effect on nerve fibers, reducing pain in target areas, but leaving other sensory capabilities intact. A procedure developed more than 30 years ago

69. Lumbar Facet Medial Branch Block Needle position at junction of SAP and TP Medial branch of Dorsal ramus

70. FACET JOINTS - RF DENERVATION PATIENTS SELECTION - FLOW CHART FACET JOINTS BLOCK ( diagnostic – prognostic ) Unsteady pain relief Lasting pain releif Facet joints block repetition Unsteady pain relief RF DENERVATION

71. Sacroiliac Joint

72. Sacral Iliac Joint Injection History: fall, or high velocity trauma (MVA) PE : pain over SI joint, Patrick’s test, Radiology : not very useful Diagnosis: Gold Standard is flouroscopic guided injection of SI joint using dye and lidocaine Treatment: SI joint injection with lidocaine and steroid and physical therapy. We add hylase also sometimes for better penetration of the drugs

73. Diagnostic - Sacroiliac Joint - Intraarticular injection

74. Sacral Iliac Joint Injection

75. More advanced techniques available

76. Muscles Soft Tissue ---Trigger Points

77. IN SUMMARY…..

78. Chronic Neck & Back Pain The NEW Pathway Injury. Conservative care without improvement (2-4 weeks). PAIN MEDICINE evaluation. Appropriate diagnostic injections. Appropriate therapeutic interventions. Rehabilitation. Radiological studies as necessary and/or surgical referral if diagnostic injections reveal surgically correctable pathology.

79. THERAPEUTIC WINDOW OF OPPORTUNITY

80. Expectations – Good quality of life

81. Treatment continuum

83. Thank you for your attention! Are there any questions?

84. NO ONE should live or die in pain