Epidural Lysis of Adhesions

2. OBJECTIVES To understand the purpose and indications for epidural lysis of adhesions To present evidence based literature for epidural lysis of adhesions To afford the pain practitioner the ability to incorporate epidural lysis procedures into a multidisciplinary pain treatment algorhythm Incidence Pain is the most common reason patients present to their physicians. LBP is the most common type of pain experienced by adults. Second leading cause of work absence IN PATIENTS <50 YEARS OLD - first is common cold Cost to society - billions $$ in: missed days of work (employer) poor job performance/productivity (employer) medical care costs disability programs (we all see numerous patients already on disablility secondary to NON-SPECIFIC LBP) early retirement - therefore early Medicare consumerIncidence Pain is the most common reason patients present to their physicians. LBP is the most common type of pain experienced by adults. Second leading cause of work absence IN PATIENTS <50 YEARS OLD - first is common cold Cost to society - billions $$ in: missed days of work (employer) poor job performance/productivity (employer) medical care costs disability programs (we all see numerous patients already on disablility secondary to NON-SPECIFIC LBP) early retirement - therefore early Medicare consumer

3. INTRODUCTION Lifetime prevalence of low back pain is 65 - 80% Post laminectomy syndrome occurs in 5 - 40% of lumbar spine operations 13% of low back pain patients have significant disability 44 million U.S. households have at least one adult with chronic pain Stats from USA Today 8/9/01Stats from USA Today 8/9/01

4. DEFINITION OF EPIDURAL LYSIS INDICATIONS EVIDENCE REGARDING LYSIS PROCEDURE PROTOCOL MULTIDISCIPLINARY TREATMENT ALGORHYTHM INTRODUCTION

5. EPIDURAL LYSIS OF ADHESIONSNOMENCLATURE Epidural neuroplasty Epidural neurolysis Epidural lysis Epidural adhesiolysis Percutaneous adhesiolysis Percutaneous epidural neuroplasty Racz�s Procedure

6. EPIDURAL LYSIS OF ADHESIONSHistory and Development 1901 Epidural injection for chronic LBP 1909 Epidural injections cure sciatica 1921 Epidurography 1989 Epidural neuroplasty

7. EPIDURAL LYSIS OF ADHESIONSDEFINITION �The site specific delivery of medication where the pressure-volume effect of medication (in the right tissue plane) frees up the nerve root, reduces swelling and allows the return of mobility� -Gabor Racz, MD, Personal Communication

8. EPIDURAL LYSIS OF ADHESIONSDEFINITION The disruption of scar tissue/fibrosis and freeing of spinal nerve roots in the epidural space to allow deposition of medication at the site of pathology and pain generation in order to improve function Richard Epter, MD Personal Communication

9. EPIDURAL LYSIS OF ADHESIONSMECHANISM Hydraulic Chemical Mechanical

10. Epidural adhesions alone do not cause pain!

11. SPINAL PAIN GENERATORS Nerve Root Dura � Radicular Ventral Dura � Axial Facet Joint � Axial Sacroiliac Joint � Axial Disc � Axial Bone/Vertebral Periosteum � Axial Muscle � Axial / Diffuse Ligaments � PLL � Axial Fascia - Axial

12. SPINAL PAIN GENERATORS PROPOSED ETIOLOGIES OF CHRONIC LOW BACK AND LOWER EXTREMITY PAIN Inflammation Edema Fibrosis Vascular compromise / venous congestion Biochemical influences Post lumbar laminectomy syndrome Disc herniation Spinal Stenosis Neural compression Mechanical pressure on PLL Decreased/absent nutrients to spinal nerve root Central sensitization

13. EPIDURAL LYSIS OF ADHESIONSMECHANISMS OF PAIN Pain is produced by the movement of swollen inflamed nerve roots McCarron RF, et al, The Inflammatory Effect of the Nucleus Pulposis: A Possible Element in the Pathogenesis of Low Back Pain, Spine, 1987, 12: 760-764

14. EPIDURAL LYSIS OF ADHESIONSMECHANISMS OF PAIN Associated irritation via direct mechanical encasement of nerve roots within scar tissue And/Or Associated epidural venous engorgement with resultant nerve root edema

15. EPIDURAL LYSIS OF ADHESIONSMECHANISMS OF PAIN Scar tissue compounded pain associated with nerve root by fixing it in one position and thus increasing the susceptibility of the nerve root to tension or compression Kuslich SD, et al, The Tissue Origin of Low Back Pain and Sciatica: A Report of Pain Response to Tissue Stimulation During Operations on the Lumbar Spine Using Local Anesthesia, Orth Clin N Amer, 1991, 22: 181-187

16. EPIDURAL FIBROSISDIAGNOSIS MRI CT MYELOGRAPHY

17. EPIDURAL FIBROSISDIAGNOSIS EPIDUROGRAPHY First reported use 1921 To identify filling defects due to epidural fibrosis/scarring

18. EPIDURAL FIBROSISDIAGNOSIS Caudal epidurography was effective in correlating a filling defect with patient�s reported level of pain Racz GB, et al, Lysis of Adhesions in the Epidural Space, Techniques of Neurolysis, 1989, pp 57-72 Manchikanti L, et al, Role of Epidurography in Caudal Neuroplasty, Pain Digest, 1998, 8: 277-281

19. EPIDURAL FIBROSISETIOLOGY Surgical Non-Surgical

20. EPIDURAL FIBROSISSURGICAL ETIOLOGY �Nothing can heal like cold, hard steel.� Anonymous Orthopedic Surgeon

21. EPIDURAL FIBROSISSURGICAL ETIOLOGY POSTLAMINECTOMY SYNDROME incidence estimated at 5 to 40% of lumbar spine operations including laminectomy, fusion, microsurgery (failure rates as high as 68%) Wilkinson HA, The Role of Improper Surgery in the Etiology of the Failed Back Syndrome, The Failed Back Syndrome, 2nd Edition, 1992, pp 1-3

22. EPIDURAL FIBROSISSURGICAL ETIOLOGY Probability of recurrent pain increases after lumbar discectomy as peridural scarring increases Extensive scarring resulted in 3.2 times incidence of recurrent radicular pain Ross J, et al, Association Between Peridural Scar and Recurrent Radicular Pain After Lumbar Discectomy: Magnetic Resonance Evaluation, Neurosurgery, 1996, 38: 855-863

23. EPIDURAL FIBROSISNON-SURGICAL ETIOLOGY Annular tear Hematoma Infection Intrathecal Contrast

24. EPIDURAL FIBROSISEVIDENCE HIGH LEVELS OF INFLAMMATORY PHOSPHOLIPASE A2 IN LUMBAR DISC HERNIAITONS Spine 1990 15; 674-678 Saal, JS THE ROLE OF INFLAMMATION IN LUMBAR PAIN Spine 1995 Aug 15;20(16):1821-7 Saal, JS PHOSPHLIPASE A2 = INFLAMMATION IN THIS STUDY FROM �SPINE� PUBLISHED IN AUGUST 1995: EVIDENCE SUPPORTING INFLAMMATION AS A MAJOR CAUSE OF LOW BACK PAIN WAS PRESENTED. AS HIGH LEVELS OF PHOSPHOLIPASE A2 ARE PRESENT IN DEGENERATIVE AND HERNIATED DISKS, AND THIS INFLAMMATORY ENZYME HAS BEEN SHOWN TO PRODUCE PERINEURAL INFLAMMATION AND CONDUCTION BLOCK, IT SEEMS THAT THE CLINICAL FEATURES OF MANY LBP PATIENTS MAY BE EXPLAINED BY BIOCHEMICAL FACTORS ALONE OR IN COMBINATION WITH MECHANICAL DEFORMATION OF LUMBAR TISSUES, RATHER THAN MECHANICAL FACTORS ALONE. WHAT THIS SAYS IS - THAT WE NOW HAVE EVIDENCE FOR AN INFLAMMATORY ETIOLOGY OF LBP. IT IS BELIEVED THAT THIS INFLAMMATORY PROCESS MAY OCCUR IN CASES OF BULGING DISKS, HERNIATED DISKS AND INTERNAL DISK DISRUPTION WHERE NO OBVIOUS STRUCTURAL ABNORMALITY OF THE DISK EXISTS. AND THIS PROCESS CAN OCCUR ON A CHRONIC BASIS. I ALSO BELIEVE THIS IS WHY EPIDURAL STEROIDS WORK FOR MANY PATIENTS. [==GO TO NEXT SLIDE]IN THIS STUDY FROM �SPINE� PUBLISHED IN AUGUST 1995: EVIDENCE SUPPORTING INFLAMMATION AS A MAJOR CAUSE OF LOW BACK PAIN WAS PRESENTED. AS HIGH LEVELS OF PHOSPHOLIPASE A2 ARE PRESENT IN DEGENERATIVE AND HERNIATED DISKS, AND THIS INFLAMMATORY ENZYME HAS BEEN SHOWN TO PRODUCE PERINEURAL INFLAMMATION AND CONDUCTION BLOCK, IT SEEMS THAT THE CLINICAL FEATURES OF MANY LBP PATIENTS MAY BE EXPLAINED BY BIOCHEMICAL FACTORS ALONE OR IN COMBINATION WITH MECHANICAL DEFORMATION OF LUMBAR TISSUES, RATHER THAN MECHANICAL FACTORS ALONE. WHAT THIS SAYS IS - THAT WE NOW HAVE EVIDENCE FOR AN INFLAMMATORY ETIOLOGY OF LBP. IT IS BELIEVED THAT THIS INFLAMMATORY PROCESS MAY OCCUR IN CASES OF BULGING DISKS, HERNIATED DISKS AND INTERNAL DISK DISRUPTION WHERE NO OBVIOUS STRUCTURAL ABNORMALITY OF THE DISK EXISTS. AND THIS PROCESS CAN OCCUR ON A CHRONIC BASIS. I ALSO BELIEVE THIS IS WHY EPIDURAL STEROIDS WORK FOR MANY PATIENTS. [==GO TO NEXT SLIDE]

25. INFLAMMATORY SUBSTANCES LEAKING OUT OF INTERVERTEBRAL DISC

26. EPIDURAL FIBROSISEVIDENCE Injected homogenized nucleus pulposis results in inflammation of (dog) spinal cord segments McCarron RF, Epidural Fibrosis: Experimental Model and Therapeutic Alternatives; Techniques of Neurolysis, 1989, 87-94

27. EPIDURAL FIBROSISEVIDENCE McCarron RF, Epidural Fibrosis: Experimental Model and Therapeutic Alternatives; Techniques of Neurolysis, 1989, 87-94 Courtesy of G Racz, MD

28. EPIDURAL FIBROSISEvidence Periradicular fibrosis and vascular abnormalities occur with herniated discs Cooper, et al, Herniated Intervertebral Disc Associated Abnormalities without Inflammatory Cell Infiltration, Spine, 1995, 20: 591-598

29. EPIDURAL FIBROSISEvidence Pathological changes including perineural / intraneural fibrosis, nerve root edema, focal demyelination occur in and around the nerve root complex Hoyland, et al, Intervertebral Foramen Venous Obstruction, Spine, 1989, 14: 558-568

30. EPIDURAL LYSIS OF ADHESIONSEFFICACY

31. INTERVENTIONAL MANAGEMENT EPIDURAL STEROIDS Safety Efficacy Technique Translaminar, Transforaminal�Transsacral Cervical, Thoracic, Lumbar, Caudal Volume Medications Catheter Not all epidural steroid injections are alike!Not all epidural steroid injections are alike!

32. EPIDURAL STEROIDS Pasquier NM, et al. Injection-intra-et extraudrales de cocaine a dose minime daus le traitment de la sciatique. Bull Gen Ther 1901; 142: 196 Caussade G, et al. Traitement de al neuralgia sciatique par la methode de Sicard. Bull Soc Med Hosp Paris, 1909; 28: 865 Green PWB, et al. The role of epidural cortisone injection in the treatment of diskogenic low back pain. Clin Orthop 1980; 153: 121-125 Benzon HT. Epidural steroid injections for low back pain and lumbosacral radiculopathy. Pain 1986; 24:277-295 Bogduk N. Epidural steroids. Spine 1995; 20: 845-888 Carette S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposis. N Engl J Med 1997; 336: 1634-1640 Not all epidural steroid injections are alike!Not all epidural steroid injections are alike!

33. EPIDURAL STEROIDS EFFICACY Transforaminal > Caudal > Interlaminar Comparison of Three Routes of Epidural Steroid Injections in Low Back Pain, Manchikanti L, et al, Pain Digest, 1999, 9: 277-285 Not all epidural steroid injections are alike!Not all epidural steroid injections are alike!

34. CAUDAL ESI

35. EPIDURAL STEROIDS EFFICACY Presence or absence of epidural ligaments or scarring may prevent migration of posteriorly administered injectate to the anterior epidural space Weinstein SM, et al, Spine, 1995, 20: 1842-1846 Not all epidural steroid injections are alike!Not all epidural steroid injections are alike!

36. EPIDURAL STEROIDS EFFICACY Foraminal approach provides good ventral flow vs. Interlaminar approach predominately dorsal flow, more removed from site of inflammation Andrade A, et al, The Distribution of Radiologic Contrast Media by Lumbar Translaminar and Selective Neural Canals, Annual ISIS Meeting, Keystone, Colorado, January 1992 Not all epidural steroid injections are alike!Not all epidural steroid injections are alike!

37. INTERLAMINAR ESI

38. TRANSFORAMINAL ESI

39. EPIDURAL LYSIS OF ADHESIONSEFFICACY Percutaneous Epidural Neuroplasty: Prospective Evaluation of 0.9% NaCl Versus 10% NaCl With or Without Hyaluronidase Heavner, et al, Regional Anesthesia and Pain Medicine, 1999, 24, 3: 202-207

40. EPIDURAL LYSIS OF ADHESIONSEFFICACY PURPOSE: To determine if hypertonic saline or hyaluronidase influence treatment outcomes Heavner, et al, Regional Anesthesia and Pain Medicine, 1999, 24, 3: 202-207

41. EPIDURAL LYSIS OF ADHESIONSEFFICACY DESIGN: prospective, randomized N=83 patients (24 patients did not complete the study) Criteria: Unilateral radiating pain distal to knee and low back pain Results evaluated at 1, 3, 6 and 12 months Heavner, et al, Regional Anesthesia and Pain Medicine, 1999, 24, 3: 202-207

42. EPIDURAL LYSIS OF ADHESIONSEFFICACY DESIGN: GROUP A: hyaluronidase + hypertonic saline GROUP B: hypertonic saline GROUP C: isotonic saline GROUP D: hyaluronidase + isotonic saline Heavner, et al, Regional Anesthesia and Pain Medicine, 1999, 24, 3: 202-207

43. EPIDURAL LYSIS OF ADHESIONSEFFICACY RESULTS: All groups obtained immediate relief after treatment Max VAS scores improved in at least 25% of patients in all treatment groups at all follow up intervals Both hypertonic saline groups were less likely to require other treatments vs. normal saline groups Heavner, et al, Regional Anesthesia and Pain Medicine, 1999, 24, 3: 202-207

44. EPIDURAL LYSIS OF ADHESIONSEFFICACY CONCLUSION: The results: confirm the benefits of percutaneous epidural neuroplasty as part of an overall pain management strategy and the safety of the procedure hyaluronidase does not change the outcome less patients given hypertonic saline require additional treatments vs. patients given normal saline Heavner, et al, Regional Anesthesia and Pain Medicine, 1999, 24, 3: 202-207

45. EPIDURAL LYSIS OF ADHESIONSEFFICACY Role of Adhesiolysis and Hypertonic Saline Neurolysis in Management of Low Back Pain: Evaluation of Modification of the Racz Protocol Manchikanti L, et al, Pain Digest, 1999; 9: 91-96

46. EPIDURAL LYSIS OF ADHESIONSEFFICACY PURPOSE: To compare 3 day vs. 1 or 2 day lysis procedures for efficacy and to evaluate cost effectiveness of lysis and hypertonic saline in management of chronic low back pain Manchikanti L, et al, Role of Adhesiolysis and Hypertonic Saline Neurolysis, Pain Digest, 1999; 9: 91-96

47. EPIDURAL LYSIS OF ADHESIONSEFFICACY Modified Racz Protocol: 3 Days ? 1 or 2 Days Bupivacaine ? Lidocaine Triamcinolone ? Betamethasone Decreased Volume Manchikanti L, et al, Role of Adhesiolysis and Hypertonic Saline Neurolysis, Pain Digest, 1999; 9: 91-96

48. EPIDURAL LYSIS OF ADHESIONSEFFICACY CONCLUSION: Modified adhesiolysis is safe and cost-effective technique for relieving chronic intractable pain Repeat or multiple procedures provided significant relief with increasing duration with each procedure in a staircase fashion There was no significant difference between 1, 2 or 3 day adhesiolysis Manchikanti L, et al, Role of Adhesiolysis and Hypertonic Saline Neurolysis, Pain Digest, 1999; 9: 91-96

49. EPIDURAL LYSIS OF ADHESIONSEFFICACY Role of One Day Adhesiolysis in Management of Chronic Low Back Pain: A Randomized Clinical Trial Manchikanti L, et al, Pain Physician, 2001;4:153-166

50. EPIDURAL LYSIS OF ADHESIONSEFFICACY DESIGN: randomized, double blind, controlled N=45 patients 2 groups of 15 and 30 patients each GROUP 1: CONTROLS = meds + PT + exercise GROUP 2: cath + adhesiolysis + hypertonic saline neurolysis Manchikanti L, et al, Pain Physician, 2001;4:153-166

51. EPIDURAL LYSIS OF ADHESIONSEFFICACY RESULTS: GROUP 2 (WITH ADHESIOLYIS/10% SALINE) had statistically significant improvement in pain, physical health, mental health, functional status, psychological status and narcotic intake Manchikanti L, et al, Pain Physician, 2001;4:153-166

52. EPIDURAL LYSIS OF ADHESIONSEFFICACY RESULTS: GROUP 2 (WITH ADHESIOLYIS/10% Saline) had significant relief (>50% with 1-3 injections) 3 months: 97% 6 months: 93% 12 months: 47% Manchikanti L, et al, Pain Physician, 2001;4:153-166

53. EPIDURAL LYSIS OF ADHESIONSEFFICACY CONCLUSIONS: Epidural adhesiolysis with hypertonic saline performed on a one day basis is an effective treatment for chronic low back pain patients (without facet pain) that failed fluoroscopically directed epidural steroid injections Manchikanti L, et al, Pain Physician, 2001;4:153-166

54. EPIDURAL LYSIS OF ADHESIONSEFFICACY One Day Adhesiolysis and Hypertonic Saline Neurolysis in Treatment of Chronic Low Back Pain: A Randomized, Double-Blind Trial Manchikanti L, et al, Pain Physician, 2004;7:177-186

55. EPIDURAL LYSIS OF ADHESIONSEFFICACY DESIGN: randomized, double blind, controlled N=75 patients 3 groups of 25 patients each GROUP 1: CONTROLS = cath + no adhesiolysis + LA + NSS + steroid GROUP 2: cath + adhesiolysis +LA + NSS + steroid GROUP 3: cath + adhesiolysis + LA + 10% saline + steroid Manchikanti L, et al, Pain Physician, 2004;7:177-186

56. EPIDURAL LYSIS OF ADHESIONSEFFICACY RESULTS: GROUPS 2 & 3 (WITH ADHESIOLYIS) had statistically significant improvement vs. baseline and GROUP 1 at 3, 6 and 12 months Manchikanti L, et al, Pain Physician, 2004;7:177-186

58. EPIDURAL LYSIS OF ADHESIONSEFFICACY RESULTS: GROUPS 2 & 3 (WITH ADHESIOLYIS) at 6 & 12 months had statistically significant pain relief GROUP 2: 60% GROUP 3: 72% vs GROUP 1: 0% Manchikanti L, et al, Pain Physician, 2004;7:177-186

59. EPIDURAL LYSIS OF ADHESIONSEFFICACY RESULTS: GROUPS 2 & 3 (WITH ADHESIOLYIS) had statistically significant differences in pain relief, Oswestry Disability Index and range of motion Manchikanti L, et al, Pain Physician, 2004;7:177-186

61. EPIDURAL LYSIS OF ADHESIONSEFFICACY CONCLUSIONS: Percutaneous adhesiolysis (+/- hypertonic saline) is a safe and effective treatment for chronic refractory low back and lower extremity pain Manchikanti L, et al, Pain Physician, 2004;7:177-186

62. EPIDURAL LYSIS OF ADHESIONSEFFICACY Hyaluronidase added N=100 82% initial pain relief (vs. 68% w/o hyaluronidase) No significant long term improvement (14% vs. 12%) Arthur J, Lysis of Epidural Adhesions in the Treatment of Chronic Back Pain

63. EPIDURAL LYSIS OF ADHESIONSEFFICACY Hyaluronidase reduced the neuroplasty treatment failure rate from 18% to 6% Racz G, et al, Lysis of Epidural Adhesions, Waldman, Interventional Pain Management, 1996, 339-351

64. EPIDURAL LYSIS OF ADHESIONSPROCEDURE

65. EPIDURAL LYSIS OF ADHESIONSINDICATIONS Epidural Scarring / Fibrosis Failed Back/Neck Surgery Syndrome Disc Disruption Spinal Stenosis Vertebral Compression Fractures Multilevel Degenerative Arthritis

66. TECHNICAL CONCEPTS AWAKE PATIENT Sterile Technique Fluoroscopic Guidance Fluoroscopic Anatomy 3-D Relationships Biplanar Fluoroscopy Water Soluble Dye Real-time Fluoroscopy Tunnel Vision Curved/Blunt Needles Small Bore Extension Miscellaneous: Read Labels Consistent Routine Same Personnel

67. PROCEDURE Obtain informed consent NPO Appropriate monitoring +/ - Sedation

68. PROCEDURELESION SPECIFICITY Know your target point based on patient�s history, physical exam, pain/dermatomal pattern

71. LUMBAR ANATOMY

72. TECHNIQUEPOSITIONING & APPROACH

73. PROCEDUREPOSITIONING Prone (vs lateral decubitus) Pillows beneath abdomen/pelvis, shins Arms comfortable, abducted less than 90 degrees

74. PROCEDURETECHNIQUE Meticulous attention to sterile technique Sterile prep/drape � gluteal fold gauze Exact midline AP fluro SQ Local anesthetic (bupivacaine 0.25% / ropivacaine 0.2%) infiltration with 25/27g needle Skin nick with 18g needle

75. TECHNIQUECAUDAL ACCESS

76. TECHNIQUECAUDAL ACCESS

77. PROCEDURETECHNIQUE Epidural Access: 15g or 16g RX Coud� or Straight 16g R.K.� Straight 18g RX Coud� or Straight(21g Versakath only) SCA FIC

78. EQUIPMENT

79. PROCEDURETECHNIQUE Insert needle via sacral hiatus (2 cm lateral and inferior) not above S3 foramina Aspirate and then inject 10 ml iohexol 240 (Omnipaque); observe initial few mls in lateral view to confirm cephalad spread and rule out vascular, subdural / subarachnoid injection Identify and document filling defect

80. TECHNIQUECAUDAL ACCESS

81. TECHNIQUECAUDAL ACCESS

82. TECHNIQUECAUDAL ACCESS

83. TECHNIQUECAUDAL ACCESS

84. TECHNIQUECAUDAL ACCESS

85. TECHNIQUECAUDAL ACCESS

86. TECHNIQUECAUDAL ACCESS

87. TECHNIQUECAUDAL ACCESS

88. TECHNIQUECAUDAL ACCESS

89. LYSIS OF ADHESIONS

90. PROCEDURETECHNIQUE Rotate bevel needle 135 degrees ventrolateral to desired side Place 15 degree bend in catheter tip Advance spring tip catheter to desired lesion site � warn patient of possible paresthesias Confirm ventrolateral catheter placement in AP and lateral views Remove stylet and needle Place connector on catheter

91. PROCEDURETECHNIQUE Must document runoff � up and down epidural space and/or out foramen

92. PROCEDURETECHNIQUE Aspirate catheter and inject an additional 3 � 5 (up to 10) ml of iohexol Check lower extremity motor function Rule out loculation, vascular, subdural / subarachnoid injection Aspirate and inject hyaluronidase 1500u Aspirate and inject an additional 2 ml of iohexol

93. LYSIS OF ADHESIONS

94. LYSIS OF ADHESIONS

95. LYSIS OF ADHESIONS

96. LYSIS OF ADHESIONS

97. PROCEDURETECHNIQUE Visualize and document dye spread into area of previous filling defect and outline the targeted nerve root Aspirate and inject preservative free ropivacaine / bupivacaine and triamcinolone / decadron Secure catheter and place 0.2 micron filter Observe for 30 minutes to rule out subarachnoid / subdural injection **Aspirate and inject ropivacaine / bupivacaine Begin preservative free 10% saline infusion

98. LYSIS OF ADHESIONS

99. PROCEDURETECHNIQUE

100. PROCEDURETECHNIQUE ONE DAY Flush catheter with 1.5 ml preservative free saline Discontinue catheter Apply triple antibiotic ointment Apply dressing / band aid Provide discharge instructions Follow up

101. PROCEDURETECHNIQUE TWO OR THREE DAY Aspirate catheter and inject local anesthetic Wait 15 minutes and begin 6-10 ml 10% saline infusion over 20-30 minutes Flush catheter with 1.5 ml preservative free saline Discontinue catheter

102. PROCEDURETECHNIQUE TWO OR THREE DAY Apply triple antibiotic ointment Apply dressing / band aid Provide discharge instructions Follow up

103. CERVICAL ESI

104. CERVICAL LOA

105. CERVICAL LOA

106. EPIDURAL LYSIS OF ADHESIONSPOTENTIAL COMPLICATIONS Bleeding Nerve injury Spinal cord ischemia / paralysis Infection Allergic reactions Subdural/subarachnoid injection Bowel/bladder dysfunction Cardiac arrhythmias Perineal numbness (up to 1 month) Catheter shearing

107. COMPLICATIONSSUBDURAL

108. MULTIDISCIPLINARY TREATMENT

109. MULTIDISCIPLINARY TREATMENT PHILOSOPHY GOAL = FUNCTIONAL RESTORATION Early vs. Late Treatment Make a DIAGNOSIS Algorhythm Conservative Do No Harm!! EARLY VS LATE: Preemptive Analgesia Tachyphylaxis (Local Anesthetics) Prevention of Neuropathic Pain, Central Sensitization/Windup Phenomenon, chasing with more and more=behind the 8 ball ALGORHYTHM: Systematic Approach for Evaluation & Management CONSERVATIVE: Always begin with the least risky option DO NO HARM: What we learned in Med School REFERRAL: This is the big question!! As physicians we should all do what is REASONABLE. Determine your level of comfort with treatment and then REFER when appropriate based on your best judgement.EARLY VS LATE: Preemptive Analgesia Tachyphylaxis (Local Anesthetics) Prevention of Neuropathic Pain, Central Sensitization/Windup Phenomenon, chasing with more and more=behind the 8 ball ALGORHYTHM: Systematic Approach for Evaluation & Management CONSERVATIVE: Always begin with the least risky option DO NO HARM: What we learned in Med School REFERRAL: This is the big question!! As physicians we should all do what is REASONABLE. Determine your level of comfort with treatment and then REFER when appropriate based on your best judgement.

110. MULTIDISCIPLINARY TREATMENT PHILOSOPHY

111. MULTIDISCIPLINARY TREATMENT PHILOSOPHY EARLY VS LATE: Preemptive Analgesia Tachyphylaxis (Local Anesthetics) Prevention of Neuropathic Pain, Central Sensitization/Windup Phenomenon, chasing with more and more=behind the 8 ball ALGORHYTHM: Systematic Approach for Evaluation & Management CONSERVATIVE: Always begin with the least risky option DO NO HARM: What we learned in Med School REFERRAL: This is the big question!! As physicians we should all do what is REASONABLE. Determine your level of comfort with treatment and then REFER when appropriate based on your best judgement.EARLY VS LATE: Preemptive Analgesia Tachyphylaxis (Local Anesthetics) Prevention of Neuropathic Pain, Central Sensitization/Windup Phenomenon, chasing with more and more=behind the 8 ball ALGORHYTHM: Systematic Approach for Evaluation & Management CONSERVATIVE: Always begin with the least risky option DO NO HARM: What we learned in Med School REFERRAL: This is the big question!! As physicians we should all do what is REASONABLE. Determine your level of comfort with treatment and then REFER when appropriate based on your best judgement.

112. MULTIDISCIPLINARY TREATMENT PHILOSOPHY EARLY VS LATE: Preemptive Analgesia Tachyphylaxis (Local Anesthetics) Prevention of Neuropathic Pain, Central Sensitization/Windup Phenomenon, chasing with more and more=behind the 8 ball ALGORHYTHM: Systematic Approach for Evaluation & Management CONSERVATIVE: Always begin with the least risky option DO NO HARM: What we learned in Med School REFERRAL: This is the big question!! As physicians we should all do what is REASONABLE. Determine your level of comfort with treatment and then REFER when appropriate based on your best judgement.EARLY VS LATE: Preemptive Analgesia Tachyphylaxis (Local Anesthetics) Prevention of Neuropathic Pain, Central Sensitization/Windup Phenomenon, chasing with more and more=behind the 8 ball ALGORHYTHM: Systematic Approach for Evaluation & Management CONSERVATIVE: Always begin with the least risky option DO NO HARM: What we learned in Med School REFERRAL: This is the big question!! As physicians we should all do what is REASONABLE. Determine your level of comfort with treatment and then REFER when appropriate based on your best judgement.

113. MULTIDISCIPLINARY TREATMENT PHILOSOPHY NERVE BLOCKS / INTERVENTIONS ADVANTAGES: Facilitate PT/Activity Specific Pain Relief Demonstrates Compliance Low Risk Lower Cost, Risk, Side Effects vs. Surgery Reduce Medications Outpatient Procedure NERVE BLOCKS PROVIDE SIGNIFICANTLY MORE SPECIFIC RELIEF THAN ANY OTHER MODALITY - ATLEAST FOR A PERIOD OF TIME. I SEE MANY PATIENTS WHO WERE UNABLE TO TOLERATE A PT REGIMEN WITHOUT NERVE BLOCKS BUT WITH THEM ACHIEVE PROGRESS. THOSE WHERE NO BENEFIT OCCURS ARE OFTEN PATIENTS WITH SIGNIFICANT ISSUES REGARDING SECONDARY GAIN AND LITTLE MOTIVATION TO IMPROVE. THE MOST SINGLE IMPORTANT ADVANTAGE OF NERVE BLOCKS IS THAT THEY FACILITATE PT. ACCEPTANCE OF NERVE BLOCKS AS A PART OF THE PAIN MANAGEMENT REGIMEN DEMONSTRATES COMPLIANCE. WE ALL KNOW THE PATIENT WHO IS TOO SCARED TO HAVE A NERVE BLOCK BECAUSE THEY ARE AFRAID OF NEEDLES BUT REPORT A PAIN SCORE OF 10. THIS SEEMS TO BE MORE COMMON IN THE WC POPULATION - ATLEAST IN MY PRACTICE. THESE ARE LOW RISK PROCEDURES IN THE HANDS OF A SKILLED ANESTHESIOLOGIST. LOWER COST, RISK AND POTENTIAL SIDE EFFECTS VS. SURGERY. NERVE BLOCKS HELP REDUCE THE NEED FOR MEDICATIONS OR ALLOW THOSE USED TO BE MORE BENEFICIAL - LOWERS THRESHOLD. MOST BLOCKS ARE DONE ON AN OUTPATIENT BASIS. NERVE BLOCKS PROVIDE SIGNIFICANTLY MORE SPECIFIC RELIEF THAN ANY OTHER MODALITY - ATLEAST FOR A PERIOD OF TIME. I SEE MANY PATIENTS WHO WERE UNABLE TO TOLERATE A PT REGIMEN WITHOUT NERVE BLOCKS BUT WITH THEM ACHIEVE PROGRESS. THOSE WHERE NO BENEFIT OCCURS ARE OFTEN PATIENTS WITH SIGNIFICANT ISSUES REGARDING SECONDARY GAIN AND LITTLE MOTIVATION TO IMPROVE. THE MOST SINGLE IMPORTANT ADVANTAGE OF NERVE BLOCKS IS THAT THEY FACILITATE PT. ACCEPTANCE OF NERVE BLOCKS AS A PART OF THE PAIN MANAGEMENT REGIMEN DEMONSTRATES COMPLIANCE. WE ALL KNOW THE PATIENT WHO IS TOO SCARED TO HAVE A NERVE BLOCK BECAUSE THEY ARE AFRAID OF NEEDLES BUT REPORT A PAIN SCORE OF 10. THIS SEEMS TO BE MORE COMMON IN THE WC POPULATION - ATLEAST IN MY PRACTICE. THESE ARE LOW RISK PROCEDURES IN THE HANDS OF A SKILLED ANESTHESIOLOGIST. LOWER COST, RISK AND POTENTIAL SIDE EFFECTS VS. SURGERY. NERVE BLOCKS HELP REDUCE THE NEED FOR MEDICATIONS OR ALLOW THOSE USED TO BE MORE BENEFICIAL - LOWERS THRESHOLD. MOST BLOCKS ARE DONE ON AN OUTPATIENT BASIS.

114. MULTIDISCIPLINARY TREATMENT PHILOSOPHY PHYSICAL THERAPY Evaluation & Assessment Passive Modalities Passive Exercises Active Exercises Home Exercises Wellness Program PASSIVE: Heat/Ice Ultrasound Electrical Stimualtion Iontophoresis TENS, MENS PASSIVE: Heat/Ice Ultrasound Electrical Stimualtion Iontophoresis TENS, MENS

115. MULTIDISCIPLINARY TREATMENT PHILOSOPHY OUTCOME MEASURES: ADLs Quality of Life Patient Satisfaction Pain Character/Pattern Pain Intensity / VAS Pain Medication Return to Work

116. CONCLUSION Epidural LOA is a reasonable, safe and cost effective pain management technique that can be utilized successfully, in properly selected patients, to treat a variety of chronic pain conditions I HOPE THAT FROM OUR DISCUSSION TODAY I HAVE BEEN ABLE TO PROVIDE YOU WITH AN (ENTHUSIASTIC) VIEW OF THE CAUSES OF LBP, THE EVALUATION OF LBP AND ITS MANAGEMENT. AND LASTLY, I JUST WANT TO LEAVE YOU WITH THE FOLLOWING (THOUGHTS):I HOPE THAT FROM OUR DISCUSSION TODAY I HAVE BEEN ABLE TO PROVIDE YOU WITH AN (ENTHUSIASTIC) VIEW OF THE CAUSES OF LBP, THE EVALUATION OF LBP AND ITS MANAGEMENT. AND LASTLY, I JUST WANT TO LEAVE YOU WITH THE FOLLOWING (THOUGHTS):