Failed Back Surgery Syndrome Neuromodulation/Implantable device/Advanced Pain Therapy Spinal Cord/Peripheral/field Nerve Stimulator Intraspinal Drug Delivery /Morphine pump

1. Max Wirjo,MD,FRCPC,DABA.
Director, Integrated Pain Medicine.
The Permanente Medical Group,
Kaiser Fresno Medical Center, California, USA

3. Systematic approach based on pain generators
of the spine :
Posterior compartment : all structures innervated
by dorsal ramus of the spinal nerve, i.e. Facet joint /
Z joint
Neuraxial compartment : all structures within the
epidural space and neural pathways
Anterior compartment : vertebral bodies and
intervertebral disc

5. -Intra-articular Facet injection
-Medial Branch block
-Radiofrequency Ablation of the medial branch.

9. -Translaminar Epidural Steroid injection
-Transforaminal Epidural Steroid injection
-Selective Nerve Root block
-Pulse RFA of nerve root/DRG

14. Anterior Compartment
Discogenic pain:
- Discography (Provocative)
- IDET (Intradiscal Electrothermal Therapy)
- Transdiscal Biacuplasty
Vertebral body compression fracture;
- Vertebroplasty
- Kyphoplasty

15. IDET

16. Kyphoplasty (or Vertebroplasty)

17. Kyphoplasty

18. Kyphoplasty

19. Spinal Stenosis
Bulging disc
Facet hypertrophy:
Ligamentum flavum hypertrophy
Treatment:
- Lumbar Epidural Steroid
- RFA of the medial branch
- MILD (Minimally Invasive Lumbar
Decompression)

21. MILD - Epidurogram

22. MILD – portal

23. MILD – bone sculpture

24. MILD – tissue sculpture

25. Failed Back Surgery Syndrome
Neuromodulation/Implantable
device/Advanced Pain Therapy
Spinal Cord/Peripheral/field Nerve
Stimulator
Intraspinal Drug Delivery /Morphine
pump

26. Pain Management Procedures
Advanced Pain Therapy
RFA:
 Heat
 Pulse
Spinal Cord Stimulator
 Trial
 Permanent
 All done as outpatient surgery
Morphine/Baclofen pump
 Trial (as outpatient, baclofen needs 8 hr monitoring
 Permanent, done as inpatient

27. Sacroiliac injection

28. Spinal Cord Stimulator

29. Spinal Cord Stimulator

30. Intraspinal Drug Delivery
system/ Morphine pump

32. Intrathecal Drug Delivery
Pump
1.Narcotic : Morphine, Dilaudid, Ziconotide , Fentanyl.
with Clonidine/ Baclofen/ Bupivacaine added.
2.Baclofen ( Liorisal ) for Spastic Disorder
i.e. CP, MS, Spinal Cord Injury, Stroke