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Pain management
- 1. Interventional Procedures in Chronic Pain DrBrendan Moore Specialist Pain Medicine Physician Adjunct Associate Professor University of Queensland
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- 4. Origins of lumbarpain • Degenerative Discs • Vertebral fractures • Spinal / Foraminal Stenosis • Disc Bulge / Prolapse • Facet Joint • Muscle / Soft tissue
- 5. Invasive Treatment Options •Surgery • Facet Joint Injection • Radiofrequency medial branch ablation • Epidural / Caudal steroid • Vertebroplasty • Coeliac / Lumbar Sympathetic Plexus Blocks • Sacro-iliac Joint injection
- 6. Posterior Elements • FacetJoints frequently implicated in pain • Mechanical back pain with upper leg and buttock radiation
- 8. Procedures • Epidural injections –Cervical, Thoracic, Lumbar, Caudal • Facet joint injections • Sacroiliac joint injections • Medial branch blocks • Radiofrequency nerve ablation
- 9. Epidural injections • Mosteffective 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
- 10. 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
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- 13. 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
- 14. Facet Joint Injection •Primarily diagnostic • 25G Spinal needle • LA + Steroid • Steroid confers possible longer term benefit
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- 16. Medial branch nerveablation • Diagnostic medial branch blocks • Local anaesthetic + steroid • Progress to radiofrequency ablation if diagnostic block indicative of long-term benefit
- 17. Medial Branch NerveAblation • Denervation of Medial Branch via Radiofrequency Neurotomy
- 18. Radiofrequency neurotomy X-ray toconfirm 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
- 19. Cervical radiofrequency neurotomy Positionfor C2/3 and C3/4 facet joint radiofrequency
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- 21. Cervical radiofrequency neurotomy– lateral view Marker shows needle at C2/3 facet joint
- 24. Opioid prescribing: dose limitsand considerations
- 25. Suggested maximum opioiddose • 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
- 26. 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
- 27. FPM Opioid CalculatorApp Free download