Interventional%20Pain%20Management%20for%20LBP

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Interventional Pain Management for LBP

• Dr. dr. Yusak M.T. Siahaan, Sp.S, FIPP
• Siloam Hospital Lippo Village/ Medical Faculty
  Pelita Harapan University

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What is Pain?

• Pain is an unpleasant sensory and/or emotional
  experience associated with actual or potential
  tissue damage, or described in terms of such
  damage.
• (International Association for the Study of Pain)

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Traditional Biological model of pain

• Injury
• - Nociception
• - Neuropathy

Pain
Impact on activity, mood
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Treatment implications?

Nociception or neuropathy
Pain-free
Normal activity mood restored
(e.g. Bogduk N. Management of chronic low back
pain. Med J Aust 2004 180 (2) 79-83)
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Pharmacologic Control of Pain
WHO Pain Ladder
http//erlewinedesign.com/end-of-life-care/gfx/who
_ladder.gif
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Treatment of Pain
Recovery
Operation
Strong opioids
Weak opioids /- non-opioids
Non-opioids
World of Misery
Non-pharmacological methods
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Treatment of Pain
Recovery
Operation
IPM
Strong opioids
Weak opioids /- non-opioids
Non-opioids
Non-pharmacological methods
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Interventional Pain Management

• 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.

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Interventional Pain Management

• Minimally invasive procedures including
  percutaneous precision needle placement, with
  placement of drugs in targeted areas or ablation
  of targeted nerves.

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IPM are group of procedures with different
mechanism of actions

1. Targeted delivery of drugs
2. Blocking of nerve signals corrects neuropathy.

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Therapeutic IPM procedures

• Trigeminal nv. Block at ganglion or branch
• Spheno-palatine ganglion block
• Glosso-pharyngeal nerve block
• Stellate ganglion block
• Thoracic sympathetic block
• Celiac Plexus block
• Superior Hypogastric plexus block
• Ganglion Impar block

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104 patients low back pain without any
identifiable cause

• Facet joint(s) disease in 24
• Lumbar nerve root and facet disease in 24
• Facet(s) and sacroiliac joint(s) in 4
• Lumbar nerve root irritation in 20
• Disc disorder in 7
• Sacroiliac joint in 6
• Sympathetic dystrophy in 2
• No cause was identified in 13

Ref Pang WW et al. Application of spinal pain
mapping in the diagnosis of low back
painanalysis of 104 cases. Acta Anaesthesiol Sin
1998 3671-74.
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Area of pain Low Back
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120 patients low back pain without any
identifiable cause

• Facet joint pain in 40,
• Discogenic pain in 26,
• Sacroiliac joint pain in 2,
• Segmental dural/ nerve root pain in 13
• No cause was identified in 19

Ref Manchikanti L et al. Evaluation of the
relative contributions of various structures in
chronic low back pain. Pain Physician 2001
4308-316.
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Diagnostic IPM procedures

• Diagnostic nerve block
• Facet joint block
• Provocative discography
• Epidurogram, epiduroscopy
• Selective nerve root block
• SI joint block
• Sympathetic Nv. Block

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Discogenic Pain

• Young and Aprill 2000, Young et al 2003
• Characteristics associated with disc pain
• Pain at or above L5
• Obstruction to movement
• Change in loss of movement with repeated
  movements
• Centralisation / peripheralisation
• Pain rising from sitting
  

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MRI High Intensity Zone
Carragee 2005, NEJM
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Discogenic pain management

• Treatment
• Medication
• Functional restoration
• Intradiscal Electrothermal Therapy (IDET)
• Lumbar fusion

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Management Medication

• Analgesics
• NSAIDS (mechanism of pain relief unclear)
• Tylenol, Tramadol
• Opioids (time contingent use most effective)
• Anti-inflammatories
• NSAIDs (consider side effects)
• Corticosteroids (consider side effects)
• Muscle relaxants

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Discography

• Provocative test
• Injection of contrast directly into disc
• Localizes source of back pain
• Positive Test A concordant pain pattern
  (reproduction of usual typical pain)
• Very controversial

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Lumbar Discography
Fluoroscopic placement of needles
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Discography Interpretation
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Sacroiliac Joint Pain
The typical pain of the SIJ is deep, intense,
variable low back and buttock pain, which may
refer pain, numbness, and tingling in various
patterns down the leg. It may be constant, or
vary with position and movement
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SI Joint Anatomy
The sacroiliac articulation is an amphiarthrodial
joint, formed between the auricular surfaces of
the sacrum and the ilium. The articular surface
of each bone is covered with a thin plate of
cartilage. They are separated by a space
containing a synovial-like fluid hence, the
joint presents the characteristics of a
diarthrosis. The ligaments surrounding the joint
are the interosseous ligament and the anterior
and posterior SI ligaments.
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SI Joint Anatomy Injection USG-Guided
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SI Joint Anatomy USG Injection
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Sacroiliac Joint Injection Carm Guided
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Sacroiliac Joint Injection Carm Guided
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Sacroiliac Joint Injection Carm Guided
needle
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• Piriformis Syndrome Pain

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Piriformis Syndrome Introduction

• Approximately 6-8 of low back pain can be
  attributed to the piriformis syndrome, which
  remains a diagnosis of exclusion,
• Piriformis syndrome is considered by many
  clinicians as a condition in which muscle
  physically irritates the sciatic nerve because of
  muscle strain, overuse, or anatomic anomaly.
• Persons with this syndrome often present with
  ipsilateral numbness, tingling, and pain in the
  buttocks, thigh, and leg, resembling features of
  sciatica.

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Piriformis Syndrome Anatomy
The piriformis muscle lies deep in the gluteus
maximus.1 Originating from the anterior aspect of
the sacrum and inserting into the upper border of
the greater trochanter, its contraction causes an
abduction and lateral rotation of the thigh.
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Piriformis Muscle Anatomy
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Ultrasound-Guided Piriformis Muscle Scanning
Transverse ultrasound view of the sciatic nerve.
Longitudinal ultrasound view of the piriformis
muscle
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Ultrasound-Guided Piriformis Muscle Injection
Technique
A curvilinear transducer is placed in a
transverse orientation to first identify the
sacral cornuae and is then moved toward the
greater trochanter until the lateral edge of the
sacrum is observed. The transducer is moved
further laterally until the greater trochanter
and ilium are both observed .
The piriformis muscle will appear as a
hyperechoic band lying between the lateral edge
of the sacrum and the greater trochanter and deep
in the gluteus maximus muscle. The sciatic nerve
appears as an oval-shaped hypoechoic structure
lying deep in the piriformis muscle
Fishman LM, Dombi GW, Michaelsen C, et al
Piriformis syndrome Diagnosis, treatment, and
outcome-a 10-year study. Arch Phys Med Rehabil
200283295-301
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Ultrasound-Guided Piriformis Muscle Scanning
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Ultrasound-Guided Piriformis Muscle Injection
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Piriformis Injection C Arm Guided
The piriformis muscle lies deep in the gluteus
maximus.1 Originating from the anterior aspect of
the sacrum and inserting into the upper border of
the greater trochanter, its contraction causes an
abduction and lateral rotation of the thigh.
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Herniated Disc pain

• A herniated lumbar disc can press on the nerves
  in the spine and may cause pain, numbness,
  tingling or weakness of the leg called
  "sciatica." Sciatica affects about 1-2 of all
  people, usually between the ages of 30 and 50.
• A herniated lumbar disc may also cause back pain,
  although back pain alone (without leg pain) can
  have many causes other than a herniated disc.

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Herniated Disc pain symptoms

• Low Back to lower leg
• Sharp, shooting or burning pain
• Decreased with standing increased with bending
  or sitting
• Positive straight leg raise test

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Herniated Disc pain symptoms
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Herniated Disc Transforaminal Epidural Steroid
Injection

• Consists of a mixture of saline, local anesthetic
  and the long acting steroid
• The long acting steroid reduces the inflammation
  and swelling of spinal nerve roots and other
  tissues surrounding the spinal nerve root

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Transforaminal Epidural Steroid
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Transforaminal Epidural Steroid
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Intralaminal Epidural Steroid Injection
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Intralaminal Epidural Steroid Injection
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Intralaminal Epidural Steroid Injection
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Epidural Caudal Injection
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Epidural Caudal Injection

• Epidural administration of corticosteroids is one
  of the commonly used interventions in managing
  chronic low backpain . The lumbar epidural space
  is accessible eitherby caudal, interlaminar, or
  transforaminal routes . Reports of the
  effectiveness of all types of epidural
  corticosteroids irrespective of route of
  administration have varied from 18 to 90

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Epidural Caudal Injection Anatomy

• The philosophy of epidural steroid injections is
  based on the premise that the corticosteroid
  delivered into the epidural space attains higher
  local concentrations over an inflamed nerve root
  and will be more effective than a steroid
  administered either orally or by intramuscular
• pain relief outlasting by hours, days, and
  sometimes
• Caudal epidurals have been described as very
  effective, with easy entry without dural
  puncture.

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Epidural Caudal Injection USG-Guided
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Epidural Caudal Injection USG-Guided
The transducer was placed transversely on the
sacral hiatus and checked intercornual distance,
thickness of sacrococcygeal membrane, depth of
caudal space. (A) Photo, (B) Ultrasound finding.
Heunguyn Jung, M.D., Dae Hee Kim, M.D., Seong Hun
Jeon, M.D., The Effectiveness of Ultrasound
Guidance in Caudal Epidural Block J Korean Soc
Spine Surg. 2013 Dec20(4)178-183
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Epidural Caudal USG-Guided Injection
The transducer was rotated 90 degrees to obtain
the longitudinal view of sacral hiatus. (A)
Photo, (B) Ultrasound finding.
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Epidural Caudal Injection USG-Guided
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Epidural Caudal Injection USG-Guided
Needle was inserted to caudal epidural space
under ultrasound guidance. (A) Photo, (B)
Ultrasound finding.
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Epidural Caudal Injection USG-Guided
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Epidural Caudal Injection C Arm Guided
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Epidural Caudal Injection C Arm Guided
Epidural Caudal Injection C Arm Guided
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Facet Joint Pain Background

• Facet joints responsible for spinal pain in 15
  to 45 of patients with low back pain ,
• Manchikanti L, et al (2004) 54 to 67 of
  patients with neck pain, and 42 to 48 of
  patients with thoracic pain
• Mostly remains undiagnosed with CT/MRI

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Facet Joint Pain Pattern

• Most patients will have a persisting point
  tenderness overlying the inflamed facet joints
  and some degree of loss in the spinal muscle
  flexibility
• Low back pain from the facet joints often
  radiates down into the buttocks and down the back
  of the upper leg. The pain is rarely present in
  the front of the leg, or rarely radiates below
  the knee or into the foot, as pain from a disc
  herniation often does.

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Facet Joint pain treatment

• Postural Rehabilitation
• Anti-inflamatory drugs
• Intervetebral Differential Dynamics (IDD)
• Therapeutic injections
• Facet joint injection
• Medial Branch block

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Ultrasound-Guided Lumbar Facet Nerve Blocks
Longitudinal facet views were obtained by curved
tranducer to identify the different spinal
segments (A), longitudial facet view by
ultrasound showed L3-4, L4-5, and L5-S1 facet
joints (B).
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Facet Joint Pain Anatomy
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Ultrasound-Guided Lumbar Facet Nerve Blocks
Needle insertion between the superior articular
process and on the upper edge of the transverse
process.SP Spinous process, FJ Facet joint, TP
Transverse process.
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Facet Joint Injection C Arm Guided
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Radiofrequency Ablation