In terventio nal Pain Management for Chronic Spinal Pain. Manonmani Antony, M.D. Sussex Pain Relief Center Georgetown, Delaware Western Sussex County Conference Saturday, July 20, 2013. Bio & Disclaimer. Manonmani Antony, MD Board Certified: ABA, ABA subspecialty Pain Medicine
In terventio nal Pain Management for Chronic Spinal Pain
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Bio & Disclaimer Manonmani Antony, MD Board Certified: ABA, ABA subspecialty Pain Medicine ASA’s 2009 Certificate in Business Administration(CBA) CEDIR/AMA Guides 6th ed. AAAP Certified - Buprenorphine in Rx of Opioid Dependence Founder: Sussex Pain Relief Center LLC – “The Preferred Pain Relief Center for Patients and Their Providers in Southern Delaware.” Pain Management Consultant, Nanticoke Health Services since 2005 Delaware Today’s Top Doctors for 2012 No outside funding, no grants, no support from industry 7/20/2013
Objectives Recognize interventional pain management as the discipline of medicine devoted to the diagnosis and treatment of pain Recognize interventional techniques as minimally invasive procedures and some surgical techniques Recognize management of back pain using interventional pain procedures 7/20/2013
Objectives Recognize management of thoracic pain using interventional pain procedures Recognize management of neck pain using interventional pain procedures Recognize management of pain with implantables and MILD procedure Recognize procedure-related complications and new technologies 7/20/2013
Chronic Pain-Definition An unpleasant sensory & emotional experience associated with actual tissue damage or described in terms of such damage. (IASP) Pain that persists 6 months after an injury, and beyond the usual course of acute disease, that is associated with chronic pathological process and may not be amenable for routine pain control methods, and healing may never occur (ASIPP) 7/20/2013
Interventional Pain Management-Definition The discipline of medicine devoted to the diagnosis and treatment of pain and related disorders by the application of interventional techniques in managing sub-acute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatments.(NUCC) (National Uniform Claims Committee) 7/20/2013
Interventional Techniques- Definition Minimally invasive procedures, such as needle placement of drugs in targeted areas, ablation of targeted nerves, and some surgical techniques, such as discectomy and the implantation of intrathecal infusion pumps and spinal cord stimulators. (MedPAC) (Medicare Payment Advisory Commission) 7/20/2013
Evidence-based Medicine EBM is defined as a conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The following lecture is prepared based on Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain by ASIPP Pain Physician 2013, (16), S1-S48. ISBN 1533-31 7/20/2013
Introduction MANAGEMENT OF LOW BACK PAIN MANAGEMENT OF NECK PAIN MANAGEMENT OF THORACIC PAIN IMPLANTABLES MILD IPM PHARMACOLOGY-STEROIDS IPM NEW TECHNOLOGY 7/20/2013
Lumbar Radicular Pain Predominant leg or radicular pain in a dermatomal distribution Nerve root tension signs with SLRT 30 - 70 degrees or a positive cross-leg straight leg raising Corroboration of neurologic signs with muscle weakness and wasting, sensory impairment, and reflex suppression 7/20/2013
Lumbar Radicular Pain Epidural Injections: 1) Interlaminar, 2) Transforaminal and 3) Caudal Indication: Radicular pain due to disk herniation, spinal stenosis, Post–lumbar laminectomy syndrome, CRPS, PHN, Phantom Limb pain Technique: 1) Interlaminar, 2) Transforaminal and 3) Caudal approaches, Loss of resistance technique, soap bubble appearance, 30% miss rate without fluoro, blind technique Complications: 1) Interlaminar: spinal headache, spinal block, 2) Transforaminal: spinal cord injury by intravascular injection of steroids into the artery of Adamkiewicz 3) Caudal Outcome: moderate evidence for interlaminar ESI for short term pain relief, and limited evidence for long-term relief. Moderate evidence for Transforaminal-ESI for short and long-term pain relief. 7/20/2013
LTESI: Artery of Adamkiewicz Injury Clinical Significance: Artery of Adamkiewicz 79% arise from Left T8 and L1, 30% from Right Anterior spinal artery syndrome Loss of urinary and fecal continence and impaired motor function of the legs; sensory function is often preserved to a degree 7/20/2013
Disc-related pathology: Percutaneous Epidural Adhesiolysis Racz Epidural catheter Removal of epidural Fibrosis 7/20/2013 Indication: epidural Fibrosis (Scar tissue) causing Low back pain with radiculopathy Technique: Inject dye caudally, demonstrate filling defects, insert EpimedRacz catheter, steer and twist tip in circles, inject Hyaluronidase (1500 U in 10ml NS), inject local anesthetic and steroid. Followed by neural flossing exercises. Complications: spinal cord compression from loculation of the injected fluid Outcome: FBSS pts showed a reduction in pain and improvement in functional status in 73% of the epidural adhesiolysisgp compared to 12% in the control gp. Manchikanti et al. Pain Phys 2009; 12(6):E355-E368
Disc-related pathology: Discogenic Pain (diagnostic) Pressure controlled Discography Disc pathology 7/20/2013 Indications: Other pain generators have been ruled, considering surgery or p/c interventions. Surgery is planned, and the surgeon desires an assessment of the adjacent disc levels. Technique: pressure controlled discography with manometer (Discpoint) syringe and contrast medium.
Discogenic Pain – Diagnostic-Provocation Discography Positive Response 7/20/2013 Positive response is: pain ≥7/10 at pressure <50 psi , concordant pain, grade 3 or greater annular tear, ≤ 3.5 mL volume, and at least one negative control disc. Complications: Discitis, < 0.15% per patient, diminished with the double- vs. single-needle technique, screening for infection, aseptic skin preparation, styleted needles, and IV and antibiotics
Discogenic Pain-Therapeutic- IntradiscalBiacuplasty (IDB) Technique: minimally invasive procedure Two Transdiscal RF probes (Kimberly Clark) are positioned on the postereolateral sides of annulus fibrosus. The internally cooled RF probes were attached to the RF generator, and RF energy is delivered (45°C in bipolar configuration for 15 min). Complications: Discitis 7/20/2013
The Cooled RF System Cooled RF Standard RF RF 7/20/2013 RF energy heats the tissue while circulating water moderates the temperature in close proximity to the electrode or active tip. This combination creates large volume lesions without excessive heating at the electrode A Randomized, Placebo-Controlled Trial of Transdiscal Radiofrequency, Biacuplasty for Rx of Discogenic Lower Back Pain, Pain Medicine 2013; 14: 362–373
Lumbar facet Joint Pain- Diagnostic- MBB Anatomy: One facet Joint (L4-5) is innervated by 2 medal branch nerves from L3 and L4 nerve roots Technique: Diagnostic block is done by using local anesthetics only w or w/o steroids, pain diary is given to patient. If >50% pain relief, f//u with RFN Outcome: strong evidence in the diagnosis of lumbar facet joint pain. Boswell et al, Pain Physician 2007; 10:7-111 • ISSN 1533-3159 7/20/2013
Lumbar facet Joint pain –Therapeutic- Intra-articular joint injections Technique: After confirmation of intra-articular needle tip placement, w or without contrast, the joint is injected with an local anesthetic agent to complete a diagnostic block or in combination with a steroid for therapeutic injection. Outcome: moderate evidence for short term and long term pain relief, Boswell et al, Pain Physician 2007; 10:7-111 • ISSN 1533-3159 7/20/2013
Lumbar Facet Joint Pain-Therapeutic- Radiofrequency Neurotomy Technique: A 22-gauge RFL 100mm needle with a 10mm active tip is inserted, Sensory stimulation at 50 Hz up to 1v and motor stimulation at 2 Hz up to 2.5v, Lesioning at 80 deg C for 60 sec at each level Outcome: strong evidence for short term pain relief, and moderate -strong evidence for long-term relief. Boswell et al, Pain Physician 2007; 10:7-111 • ISSN 1533-3159 Repeat RFN for chronic back pain 10 months relief; 4 – 6 successful repeats Rambaransingh B, et al. Pain Med 2010 7/20/2013
