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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

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In terventio nal Pain Management for Chronic Spinal Pain


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    1. Interventional Pain Management for Chronic Spinal Pain Manonmani Antony, M.D. Sussex Pain Relief Center Georgetown, Delaware Western Sussex County Conference Saturday, July 20, 2013 7/20/2013

    2. 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

    3. 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

    4. 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

    5. 7/20/2013

    6. 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

    7. 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

    8. 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

    9. 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

    10. Spinal Interventional Techniques Guidelines by ASIPP 2013 Pain Physician 2013, (16), S1-S48. ISBN 1533-31 7/20/2013

    11. IPM –Indications: part of Multimodal Therapeutic Strategies for managing CSP 7/20/2013

    12. 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

    13. Spinal Interventional Techniques Controlled Diagnostic Interventional Therapeutic Interventional Techniques 7/20/2013 Used to identify the pain generator Facet Joint nerve blocks (MBB) Sacroiliac joint injections Provocative discography Prolonged pain relief Epidural Injections, Adhesionolysis Facet joint Interventions Intradiscal therapies Implantable therapies

    14. Spine Anatomy 7/20/2013

    15. MANAGEMENT OF LOW BACK PAIN Disc-related pathology: Spinal Stenosis, and Radiculitis (Radicular Pain) Lumbar Facet/Zygapophysial Joint Pain Sacroiliac joint pain 7/20/2013

    16. Disc-related pathology: Spinal Stenosis, and Radiculitis Diagnostic I T Therapeutic IT 7/20/2013 Diagnostic Selective Nerve Root Blocks Lumbar Discography Epidural Injections: Interlaminar, Transforaminal and Caudal. Lumbar Epidural Adhesiolysis: Thermal Annular Procedures IDB, IDET Percutaneous Disc Decompression (APLD), (PLDD

    17. Disc-related pathology: Lumbar Radicular Pain Deramatomes Illustrative Fluorscopic Anatomy 7/20/2013

    18. 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

    19. 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

    20. Lumbar Radicular Pain - Interlaminar ESI LOR Technique AP Epidurography AP View 7/20/2013

    21. Lumbar Radicular Pain - Interlaminar ESI Lateral Position Lumbar Epidurography-Lateral view 7/20/2013

    22. Lumbar Radicular Pain - Transforaminal ESI (LTESI) Nerve root filling after contrast injection Nerve root filling with partially into epidural space 7/20/2013

    23. Digital subtraction image-Live fluoroscopy (LTESI) Contrast injection for left L5-S1 Transforaminal Digital substraction view: epidural & vascular contrast pattern 7/20/2013

    24. 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

    25. Lumbar Radicular Pain - Caudal ESI Needle position for caudal AP View with contrast Injection 7/20/2013

    26. 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

    27. Disc-related pathology: Percutaneous Epidural Adhesiolysis Pre-procedure Filling defect in left L5 nerve root Post-procedure excellent filling of left L5 nerve root 7/20/2013

    28. 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.

    29. 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

    30. Discogenic Pain - Provocation Discography-Fluoroscopice images AP post-discography view Lateral post-discography view 7/20/2013

    31. Discogenic Pain - Provocation Discography-Post Discography CT Scan images Modified Dallas discogram scale Grade 0-5 Grade 0, Grade 5 Outcome: Strong evidence as imaging tool, Strong evidence that intradiscal distention can produce pain, Strong evidence to identify chronic lumbar discogenic pain, Wolfer. et al. Pain Physician 2008, (11), 513-538. 7/20/2013

    32. Discogenic Pain-Therapeutic-IDET & Diskitll IDET: Intradiscal Electro Thermal Annuloplasty Diskitll (NT 1100 and pulsed RF mode 7/20/2013

    33. 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

    34. 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

    35. 7/20/2013

    36. Lumbar Facet Joint Pain Diagnostic IT Therapeutic IT 7/20/2013 Diagnostic Lumbar Facet Joint Blocks Diagnostic MBB Radiofrequency Neurotomy Intra-articular Injections

    37. Lumbar facet Joint pain 7/20/2013

    38. 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

    39. 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

    40. 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

    41. Lumbar Facet Joint Pain-Therapeutic- Radiofrequency Neurotomy 7/20/2013

    42. Sacroiliac Joint Pain Diagnostic IT Therapeutic IT Diagnosis of Sacroiliac Joint Pain Therapeutic Sacroiliac Joint Interventions Radiofrequency Neurotomy Cooled Radiofrequency Neurotomy 7/20/2013

    43. Sacroiliac Joint Pain Needle position Pain distribution 7/20/2013

    44. Sacroiliac Joint Pain-Interventions Diagnostic Intra-articular sacroiliac joint injections with local anesthetics Therapeutic SIJ interventions Intra-articular steroid injections; peri-articular injections with Steroid, evidence: fair Pulsed radiofrequency and conventional radiofrequency neurotomy, evidence: limited 7/20/2013

    45. SIJ pain -Therapeutic Pulsed RF Cooled Probe RF Cooled radiofrequency neurotomy, evidence: fair Pain Physician: April 2013; 16:S49-S283 7/20/2013

    46. MANAGEMENT OF NECK PAIN • Cervical facet Pain • Diagnostic Cervical Facet Joint Nerve Blocks, Evidence: good • Therapeutic Cervical Facet Joint Interventions: Evidence: Intra-articular injection: Limited, RFN: Fair • Cervical radicular Pain • Therapeutic Cervical Interlaminar ESI, Evidence: Good • Cervical Discogenic Pain • Cervical Provocation Discography, Evidence: Limited 7/20/2013

    47. Cervical Facet Pain 7/20/2013

    48. Cervical facet Pain: Therapeutic- Intra-articuarinj and RFN of Medial Branch nerves Intra-articular Jt inj RFN of Medial Branch N 7/20/2013

    49. Cervical RadicularPain: Therapeutic- Cervical Interlaminar ESI 7/20/2013

    50. Cervical Discogenic Pain-Diagnostic- Provocation Discography AP view Lateral View 7/20/2013