3. Role of Interventional Care
Incorporated into multidisciplinary care
To confirm or treat a specific diagnosis
To provide definitive palliation
To assist in rehabilitation
Primarily involved in mechanical spinal
and neuropathic pain
Timing….
7. Spinal Pain - Diagnosis
Garbage in = Garbage out
Better therapies come from more specific
diagnoses
Myofascial
Neuropathic
Mechanical
Arthralgic
Discogenic
8. Myofascial
Spinal Pain
May be primary or secondary
Primary: most significant benefits from
functional/physical therapy approach
Secondary: may require additional interventions
aimed at primary cause
Trigger point injections
Traditional, but little support in literature
May assist with rehabilitation in some cases
Role for botulinum toxin?
Piriformis syndrome (Fishman LM. AJPM&R 2004;83:42-50)
12. Flouroscopic vs Blind Injections
Flouroscopic guidance is the only way to ensure that
solution travels to the target location
Flouroscopy decreases risk of complications
Flouroscopic guidance is more effective than blind
injections
Flouroscopy does have risks associated with radiation
exposure, though exposure is very limited
1
White AH, et al. Spine. 1980;5:78-86.
2
Stewart HD, et al. Br J Rheumatol. 1987;26:424-9.
3
Renfrew DL, et al. Am J Neuroradiol 1991:12:1003-7.
13. Epidural Steroid Injections
North American Spine Society. Clinical Guidelines for
Multidisciplinary Spine Care
Diagnosis and Treatment of Degenerative Lumbar Spinal
Stenosis. 2007
16. Caudal Epidural Steroid Injections
Effective for multilevel pathology including spinal stenosis
Uses most volume of any approach
Non-selective
May be performed under flouroscopic guidance or blind
19. Mechanical Spinal Pain:
Facet Arthropathy
Synovial joints extend from C1-S1
Subject to trauma & osteoarthritis
Typical findings include pain on extension
and/or rotation of cervical or lumbar spine
Lumbar: frequent cause of secondary
myofascial pain
Cervical: frequent cause of “chronic whiplash”
20. Facet Joints:
A Source of Pain?
Capsule & synovium
highly innervated
Substance P
VIP
Bradykinin
Neuropeptide Y
Clinical studies
validate source of pain
McLain RF. Spine 1994;19(5):495-501
Beaman DN. Spine 1993;18(8):1044-49
Ashton IK. J Orth Res 1992;10(1):72-8
21. Facet Therapy 64490; 64493
Fact Joint injections: Short-term palliative
Diagnosis: medial branch nerve blocks
Therapy: radiofrequency denervation
Post-denervation physical therapy for
myofascial component
Kaplan M. Spine 1998;23(17):1847-52
Barnsely L. NEJM 1994; 330(15):1047-50
Carette S. NEJM 1991;325(14):1002-7
Dreyfuss P. Spine, 2000; 25(6):1270-77
Lord SM NEJM 1996;335:1721-6
25. SIJ Injections --20796
Used to diagnose and
treat pain of of lumbo-
pelvic origin.
Common source of “back
of the hip” or buttock pain
in older adults.
Common source of pain
patients with spinal
fusion.
For our patient’s who don’t respond, or continue to have symptoms, despite oral agents and physical therapy, an injection might be appropriate. There is some debate over the use of epidural steroid injections and I hope I can provide some insight.
Let me start by saying that all epidurals are not the same. In general, medication can be directed to the epidural space using one of three routes: 1) caudally, through the sacral canal; interlaminar, through the posterior muscles and ligaments to the dorsal (posterior) epidural space; and 3) transforaminally, through the intervertebral foramen to the ventral (anterior) epidural space.
The first two approaches may be done with or without flouroscopic guidance; a transforaminal approach requires the use of flouroscopy.
