Dr. Tariqul Islam Assistant Professor Department of Neuro-radiology and Imaging National institute of Neurosciences & Hospital Dhaka, bangladesh

1. Role of Radiology In Pain
Management
Dr. Md. Tariqul Islam
MBBS, MD, FCPS (Radiology & Imaging)
Fellow in Vascular Interventional Radiology (Singapore)
Assistant Professor
Department of Neuroradiology and Imaging
National Institute of Neurosciences and Hospital
Dhaka, Bangladesh

2. Learning Objectives
 Pain Management – what is new?
 Image guided pain management
 Role of Imaging
 Different Image Guided Injections

3. Pain Management – what is
new?
 Understanding pathophysiology of pain
 Newer concepts of analgesic therapy
 Newer drugs
 Interventional pain management-
development in diagnosis and treatment
planning

4. Image guided pain
management
 It is a relatively newer subspecialty
 Performed in
◦ symptomatic patients to
 decrease pain severity,
 confirm pain generator, and
 delay or avoid surgery.

5. Cont..
 It is minimally invasive procedure for
◦ permanent or long time pain management
 It fills the gap between pharmacologic
management of pain and more invasive
procedures

6. Success of Injection depends
on..
 Symptoms correlate with imaging/MRI
findings
 Symptoms result from inflammation or
reversible condition
 Drugs reaches the inflamed tissue

7. Role Of Imaging
 Diagnostic
◦ MRI
◦ CT Scan
◦ X-ray
 Therapeutic
◦ Fluoroscopy
◦ CT Scan
◦ Ultrasonogram

8. Cont…
 Symptom-imaging Correlation
◦ Symptom specific image review
 intraforaminal/lateral extrusion
 Multilevel stenosis in MRI- dermatomal
information may indicate pain generator

9. Cont..
Verify appropriateness of requested
intervention or justify
 Segmental instability with multilevel pain
generators
◦ poor response to injections
 Initially when back pain predominates
◦ ESI, Facet injections or combination
 Neurologic claudication and radiculopathy
superimposed
◦ surgical intervention and spinal fusion

10. Cont..
 Chronic non localizing LBP
◦ Inspect disc, facet
◦ Discogenic and arthopathic abnormalities

11. Cont…
Inspect MR images for
 Marrow edema involving
◦ Facets
◦ pars defect
◦ spinous processes
◦ lumbo-sacral pseudoarthroses
 If localizing site correlates with marrow
edema or other pain generator can be
targeted for diagnostic information therapy

12. Image 1

13. Image 2

14. Image 3

15. Image 4

16. Image 5

17. Image 6

18. Image 7

19. Image 8

20. Image 9

21. Guided Injections
 Expert interventionists develop by
◦ individualized techniques, approach and
modalities like Fluoroscopy, CT or
ultrasound
◦ Training experience
◦ Resource availability
◦ institutional policy

22. Advantages of CT-guided
Intervention
 More accurate needle placement
 Safe
 Higher reimbursement
 cross sectional documentation
 In lumbar facet injections
◦ hairline joint spaces
◦ therapeutic cyst rupture can be done

23. Image 10

24. Image 11

25. Image 12

26. Image 13

27. CT Disadvantages
 Higher cost
 Higher Radiation- use low dose protocol
 Longer procedural time
 Availability
 Intravascular contrast imaging limitation

28. Fluoroscopy advantages
 Real time observation along with contrast
flow
 Less radiation hazard compared to CT
 Steep craniocaudal angulation

29. Image 14

30. Image 15

36. Fluoroscopy disadvantages
 Important structures often can not be seen
 Arterial puncture risk is there like VA
 Difficult trajectory in bone overlapping,
complex areas like ribs, transverse process
and lung relationship.

37. Solution..
 C-arm fluoroscopy with cone-beam CT

38. Ultrasonogram
 Relatively cheap
 Machine is available
 Good for extremity joints,
 Can be used in SI, Sacral hiatus ESI

39. Ultrasonogram
Disadvantages
 Difficult spine imaging as bone is not well
imaged
 Heavily operator dependent

40. Conclusion
 Role of radiology is diverse in image guided
pain management
 It plays vital role in detection of
◦ pain generator
◦ establish/rule out other pathology
◦ clinical-imaging correlation
◦ targeted placement of drugs/chemicals

41. Acknowledgements
 Dr. Md. Abdullah Yusuf
 Dr. Md. Moniruzzaman

42. Acknowledgement
Dr. Mohammad Moniruzzaman
MBBS,FCPS,FIAS
Lien I nan Scholarship 2013 (Taiwan)
Clinical & Interventional Physiatrist
Associate Professor
Physical Medicine & Rehabilitation
Department
Dhaka Medical College, Dhaka,
Bangladesh.
Dr. Md. Abdullah Yusuf,
Assistant Professor, Dept. of
Microbiology, National Institute of
Neurosciences & Hospital, Dhaka,
Bangladesh

43. NINS & H

44. Dept. Colleagues