Presented by: Dr Brendan Moore — Pain Medicine Specialist Physician Event: GP Education Day - 2013

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

2. Degenerative Lumbar Back Pain

4. Degeneration of Lumbar Spine
• Disc degeneration +
narrowing
• Osteoporosis
• Facet Joint Arthritis
• Spinal and Foraminal
stenosis
• Loss of Lumbar
concavity

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

6. Origins of lumbar pain
• Degenerative Discs
• Vertebral fractures
• Spinal / Foraminal
Stenosis
• Disc Bulge / Prolapse
• Facet Joint
• Muscle / Soft tissue
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7. Invasive Treatment Options
• Surgery
• Facet Joint Injection
• Radiofrequency medial branch ablation
• Epidural / Caudal steroid
• Vertebroplasty
• Coeliac / Lumbar Sympathetic Plexus Blocks
• Sacro-iliac Joint injection

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

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

11. 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

12. 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

13. Lumbar Epidural Injection

14. Caudal Epidural Injection

15. 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

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

17. 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

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

19. Sacro-iliac Joint Injection

20. 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

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

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

23. 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

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

25. Cervical Radiofrequency Neurotomy

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

27. Coeliac Plexus Block

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

31. Prescribing opioids
for chronic pain

32. Useful rules for prescribers
1. Opioid therapy – part of a wider pain management approach1
1. Therapeutic Guidelines, 2007. 2. Graziotti & Goucke, 1997.
2. Avoid using opioids in isolation1
3. Inform patients about the limits of opioid therapy2
4. Arrange for a trial of opioid with clear review point2
5. Regular prescription requires regular review2
6. One doctor responsible for prescribing opioids2
7. Refer to another GP or pain specialist if concerned about
prescription or if opioid therapy is not achieving desirable results2

33. 4–6 week sustained release opioid trial
• Informed consent
• Treatment contract1
• Single prescribing doctor1
• Low dose sustained release
Review at one week
• If tolerating dose, increase gradually1
• Schedule regular follow up (e.g. every 10–14 days) if
needed2
If not tolerating opioid trial
• EXIT CRITERIA1
1. Therapeutic Guidelines Ltd, 2007. 2. Graziotti & Goucke, 1997.

34. Review of opioid trial
• Discuss progress and outcomes
• Functional goals achieved?
• Medication used responsibly?
• Discuss risks / benefits of continued therapy
• Assess 4 ‘A’s1
– Analgesia
– Activity
– Adverse effects
– Aberrant drug behaviours
1. Gourlay & Heit, 2005.

35. Opioid prescribing:
dose limits and
considerations

36. 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

37. 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

38. Opioid trial guidelines
• Commence trial with low dose sustained-release
opioid
Use a lower dose and titrate slowly in patients
who are:
• Elderly
• Taking other CNS depressants
• Opioid naïve
• Have severe hepatic or renal dysfunction
1. Graziotti & Goucke, 1997.

39. Federal requirements
PBS prescription
Restricted benefit
• Chronic severe disabling pain not responding to non-
narcotic analgesics (treatment <12 months)
• If treatment required beyond 12 months, patient must be
reviewed by a second medical practitioner
• Authority required when prescribing increased quantities
of opioid and/or repeats
– By phone – 1 month’s supply with no repeats
– In writing – 1 month’s supply with 2 repeats
• Short term supply can be prescribed without an authority
Department of Health and Ageing, 2008.

40. State requirements - QLD
• If intend to prescribe S8 drugs for longer than 8 weeks,
forward a “Report to the Chief Executive” through the Drugs
of Dependence Unit (DDU)
• A treatment approval from the Chief Executive is required
prior to treating, for any controlled drug for a patient
considered to be drug dependent
• For approvals and “Reports to the Chief Executive” contact
the Drugs of Dependence Unit
– Phone 3328 9890
– Fax 3328 9821

41. Preventing doctor-shopping
Medicare Australia
Prescription Shopping Information Service
• If patient suspected of getting medicine in excess
of medical need, contact the Prescription
Shopping Information Service:
– Complete and sign the registration form available at
www.medicareaustralia.gov.au
• Registration confirmed within 2 business days (fax) or by
mail
– Information Service available 24/7 for registered GPs to:
• Find out if patient has been identified under the
Prescription Shopping Program
• Receive information on the amount and type of PBS
medicine recently supplied to that patient
 1800 631 181

42. Summary – opioid pathway
Multidimensional assessment
GP +/– practice nurse +/– others
Opioid trial
Maintenance therapy
Authority to Prescribe
Review
Exit from pathway:
i. Goals of therapy not
achieved in trial or
maintenance phase
ii. Predominance of
psychosocial issues
iii. Evidence of aberrant
drug related
behaviour
Integrated Pain Service, 2008.
Is the patient suitable for opioid therapy?