Interventional Pain Management for LBP

1. Dr. dr. Yusak M.T. Siahaan, Sp.S, FIPP Siloam Hospital Lippo Village/ Medical Faculty Pelita Harapan University Interventional Pain Management for LBP

2. 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)

3. “Traditional” Biological model of pain Injury - Nociception - Neuropathy Pain Impact on activity, mood

4. 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)

5. Pharmacologic Control of Pain WHO Pain Ladder http://erlewinedesign.com/end-of-life-care/gfx/who_ladder.gif

6. Treatment of Pain Recovery Operation Strong opioids Weak opioids +/- non-opioids Non-opioids World of Misery Non-pharmacological methods

7. Treatment of Pain Recovery Operation IPM Strong opioids Weak opioids +/- non-opioids Non-opioids Non-pharmacological methods

8. 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.

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

10. IPM are group of procedures with different mechanism of actions • Targeted delivery of drugs • Blocking of nerve signals corrects neuropathy.

11. 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

12. 104 patients low back pain without any identifiable cause Ref: Pang WW et al. Application of spinal pain mapping in the diagnosis of low back pain—analysis of 104 cases. Acta Anaesthesiol Sin 1998; 36:71-74. • 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%

13. Area of pain : Low Back

14. 120 patients low back pain without any identifiable cause Ref: Manchikanti L et al. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001; 4:308-316. 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%

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

16. 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

17. MRI : High Intensity Zone Carragee 2005, NEJM

18. Discogenic pain : management • Treatment • Medication • Functional restoration • Intradiscal Electrothermal Therapy (IDET) • Lumbar fusion

19. Management : Medication • Analgesics • NSAIDS (mechanism of pain relief unclear) • Tylenol, Tramadol • Opioids (time contingent use most effective) • Anti-inflammatories • NSAID’s (consider side effects) • Corticosteroids (consider side effects) • Muscle relaxants

20. 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

21. Lumbar Discography Fluoroscopic placement of needles

22. Discography : Interpretation

23. 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

24. 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.

25. SI Joint Anatomy Injection USG-Guided

26. SI Joint Anatomy USG Injection

27. Sacroiliac Joint Injection Carm Guided

28. Sacroiliac Joint Injection Carm Guided

29. Sacroiliac Joint Injection Carm Guided needle

30. Piriformis Syndrome Pain

31. 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.

32. 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.

33. Piriformis Muscle: Anatomy

34. Ultrasound-Guided Piriformis Muscle : Scanning Transverse ultrasound view of the sciatic nerve. Longitudinal ultrasound view of the piriformis muscle

35. 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 2002;83:295-301

36. Ultrasound-Guided Piriformis Muscle : Scanning

37. Ultrasound-Guided Piriformis Muscle Injection

38. 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.

39. 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.

40. 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

41. Herniated Disc pain : symptoms

42. 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

43. Transforaminal Epidural Steroid

44. Transforaminal Epidural Steroid

45. Intralaminal Epidural Steroid Injection

46. Intralaminal Epidural Steroid Injection

47. Intralaminal Epidural Steroid Injection

48. Epidural Caudal Injection

49. 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%

50. 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.