A brief review of interventional pain management. Diseases & treatment modalities.

1. INTERVENTIONAL SPINE &
PAIN MANAGEMENT
Dr Manish Raj MD, DA(gold medal), FISP, FMIS, FESSA Brief review by

2. Pain ??
“Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage”

3. Acute vs chronic pain
 pain that extends beyond the expected period of
healing“ or more than 2 months
 acute pain is a normal sensation triggered in the
nervous system to alert you to possible injury and
the need to take care of yourself or caused
by occurrences such as traumatic injury, surgical proc
edures, or medical disorders

4. Chronic pain – A Disease
 Chronic pain often out lives its original
causes, worsens over time, and takes on
a puzzling life of its own… there is
increasing evidence that over time,
untreated pain eventually rewrites the
central nervous system, causing
pathological changes to the brain and
spinal cord, and that these in turn
cause greater pain.
 Even more disturbingly, recent evidence
suggests that prolonged pain actually
damages parts of the brain, including
those involved in cognition.

5. Chronic pain facts …
Condition Number of Sufferers Source
Chronic Pain 100 million Americans Institute of Medicine of The
National Academies (1)
Diabetes 25.8 million Americans
(diagnosed and estimated
undiagnosed)
American Diabetes
Association
Coronary Heart Disease
(heart attack and chest pain)
Stroke
16.3 million Americans
7.0 million Americans
American Heart Association
(2)
Cancer 11.9 million Americans American Cancer Society
1. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming
Prevention, Care, Education and Research. The National Academies Press, 2011
2. 2. Heart Disease and Stroke Statistics—2011 Update: A Report From the American Heart Association. Circulation 2011, 123:e18-e209, page 20.
3. http://www.painmed.org/patientcenter/facts_on_pain.aspx

6. Chronic pain facts…
 The total annual incremental cost of health care due to pain ranges from
$560 billion to $635 billion (in 2010 dollars) in the United States, which
combines the medical costs of pain care and the economic costs related to
disability days and lost wages and productivity.
 More than half of all hospitalized patients experienced pain in the last
days of their lives and although therapies are present to alleviate most
pain for those dying of cancer, research shows that 50-75% of patients die
in moderate to severe pain.
 An estimated 20% of American adults (42 million people) report that pain
or physical discomfort disrupts their sleep a few nights a week or more.

7. Chronic pain facts …

8. What is interventional pain management ?
 Interventional pain management or interventional pain
medicine is a super-specialty of the medical specialty pain
medicine, devoted to decrease or eliminate pain with use of
invasive & non invasive techniques
 This can be accomplished in following ways:
 Interrupting the pain signal along a neural
pathway
 Remodeling anatomical source of pain
 Neuroaugmentation (SCS, PNS)
 Implantable drug delivery system

9. Conditions treated …
 Back Pain : Slip disc /Sciatica /Lumbar Radiculopathy, Spinal stenosis
Disc herniation - protrusion/extrusion/sequestration/DDD
Facet Arthritis, Sacroilitis, Vertebral compression fracture,
Failed Back surgery syndrome, Spondylolysis, spondylolisthesis
 Neck Pain : Cervical Radiculopathy,Cervical disc bulge,Cervical Facetal Arthritis, Trapezitis
 Nerve Pain : Reflex Sympathetic Dystrophy/ Complex Regional Pain Syndrome, Post Herpetic &
Intercostal Neuralgia, Diabetic neuropathy, Phantom limb pain
 Musckuloskeletal Pain : Fibromyalgia, Scapulocoastal, Shoulder/Arm/Elbow/ Leg /Knee & foot
chronic pain
 Facial pain & headache: Trigeminal Neuralgia, Intractable Headaches (Migraine, Cluster, Chronic
Daily , cervicogenic , occipital neuralgia, Tension)
 Cancer & other pain : Cancer (Abdominal,pelvic,thoracic), Post chemotherapy pain, Ischemic leg pain,
Any pain more than 3 months

10. Treating Chronic pain - conservative

11. Interventions
 Injections: Image Guided ( Fluroscopy/ USG Guided)
- Epidural( Transforaminal/ Interlaminar at cervical spine)
- Diagnostic block ( Pain Mapping) at nerve ,ganglion, muscles
- Neurolysis, joints proliferation
- Discography
 Radiofrequency ablation: High frequency alternating current
- Trigeminal/celiac/splanchnic/hypogastric/stellate /DRG ganglion
 Minimally invasive spine & pain procedures:
- Percutaneous disc modulation ( Nucleoplasty, Dekompressor,
Hydrodiscectomy, Disc-Fx, Nucleotomy, Ozone nucleolysis)
- Endoscopic discectomy ( Band- Aid surgery)
- Spinal cord & peripheral nerve stimulator , Intrathecal pump,
- Vertebroplasty, Kyphoplasty

12. Back pain - Causes
 Disc : Disc herniation of all types Bulge,
Protrusion, Extrusion, Sequestration
 Degenerative disc disease, Spinal stenosis
 Bone – Verebral compression fracture,
Trauma
 Joints – facetal arthritis, sacroilitis
 Muscles – Quadratus lumborum, Psoas,
Piriformis

13. Another cause of back problems…
Trauma
It is also possible to injure
your back due to accidents.

14. Natural History of LBP
 Acute LBP
 inflammatory or neuropathic injury
 resolves spontaneously with minimal treatment
 Intermittent, relapsing LBP
 more challenging diagnostic and treatment dilemma
 precipitates symptomatic care and more aggressive interventions
aimed at specific underlying pathology
 Unremitting, recurring chronic LBP
 structural, neurophysiological, and biopsychosocial pathology
 requires management at all these levels
 major public health problem

15. LBP Patient Treatment Prototypes
 Chronic axial LBP
 pain does not extend beyond mid-buttock
 absence of radicular pain or sensory
symptoms below the knee
 Chronic axial LBP with radiation
 pain with radiation beyond mid-buttock
 absence of radicular pain or sensory
symptoms below the knee
 Chronic axial LBP with radicular
component
 radicular pain or sensory symptoms below
the knee

16. Structure of Lumbar Spine
 Basic functional units of spine—
motion segments—consist of two
posterior zygapophyseal (facet)
joints and an intervertebral disc,
forming a tri-joint complex
Zygapophyseal
joint

17. Disc Herniation

18. Lumbar Structural Pathology and Degenerative
Cascade
 In all individuals, there
is natural, progressive
degeneration of the
motion segments over
time
 This results in anatomic,
biochemical, and
clinical sequelae
 Although lumbar motion
segment degeneration
is not a normal process,
it may not be painful
Three phases of
degeneration
Dysfunction
Instability
Stabilization

19. Risk Factors
 Pregnancy
 Poor physical conditioning
 Poor movement techniques
 Poor posture
 Occupation
 Previous back injuries
 Others – spinal disorders (e.g. scoliosis,
osteoporosis, spondylosis)

20. Considerations in the Clinical Assessment and Diagnosis of
Chronic LBP
Medical History
General
Neurologic
Psychosocial
Pain Scales/Questionnaires
Factors in the Elderly
Physical Examination
Neurologic
Diagnostic Studies
Evaluation of the Elderly
Goals of Clinical Assessment

21. Cervical Radiculopathy

22. Cervical Facetal Arthritis

23. Treatment ladder (Modified….)
Diagnostic blocks
Epidural steroids
Radiofrequency technigues
Neurostimulation
techniques
Neuroaxial
medication
Interventional Therapies
ADJUVANT ANALGESICS + PATIENTS EDUCATION

24. Spine Pain Treatment
 Neural blockade
 selective nerve root blocks
 facet joint blocks, medial branch blocks
 Neurolytic techniques
 radiofrequency neurotomies
 pulse radio frequency
 Stimulatory techniques
 spinal cord stimulation
 peripheral nerve stimulation
 Intrathecal medication pumps
 delivery into spinal cord and brain via
CSF
 Minimally invasive
 Percutaneous disc
modulation ( Nucleoplasty,
Dekompressor, Disc-Fx,
Hydrodiscectomy, Nucleotomy,
Ozone nucleolysis, IDET,
Disctrode)
 Endoscopic discectomy
(Band- Aid surgery)
 Vertebroplasty, Kyphoplasty ,
 Open spine surgery

25. STEP UP ALGORITHM
 North american spine society guidelines 2014
 Minimally Invasive spine techniques “Daniel Kim”

26. Epidural Lumbar & cervical
o Usually performed utilizing fluoroscopy
o No sedation vs conscious sedation
o Can be therapeutic or diagnostic
Selective root sleeve tranforaminal epidural
Cervical Epidural

27. Joints Interventions
Facet Joint RF Ablation
Sacroiliac joint injection
( Arthrogram)
Cervical Facet Injection (RFA)

28. OZONE NUCLEOLYSIS

29. HYDRODISCECTOMY

30. DECOMPRESSOR DISCECTOMY

31. Intradiscal Electrothermal coagulation
(IDET) & LASER

32. Nucleoplasty - Lumbar

33. Cervical Nuceloplasty

34. Disc modulation results…..

35. ENDOSCOPIC DISCECTOMY

36. SPINAL CORD STIMULATOR

37. Intrathecal pump

38. Vertebral compression fracture

39. Vertebroplasty & Kyphoplasty

40. Vertebral augmentation

41. Nerve pain( Neuropathy)
Trigeminal Neuralgia
CRPS
Post Herpetic Neuralgia
Diabetic neuropathy
Neuropathic pain

42. Radiofrequency Ablation

43. Trigeminal ganglion Rhizotomy

44. EVIDENCE BASED GUIDELINES FOR
INTERVENTIONAL PAIN MEDICINE
 EFNS guidelines on neurostimulation therapy for neuropathic pain.
Cruccu et all. Eur J Neurology 2007;14:952-70.
 Polyanalgesic consensus conference 2007: recommendations for the management of pain by intathecal
(intraspinal) drug delivery: Report of an interdisciplinary expert panel.
Deer et al. neuromodulation 2007;10:300-328
 Evidence-based guidelines for interventional pain medicine according to clinical diagnoses.
Van Kleef et al. Pain Practice 2009;9:247-51.
 Evidence based medicine. Trigeminal neuralgia.
Van Kleef et al. Pain Practice 2009;9:252-9.
 Comprehensive evidence-based guidelines for interventional techniques in the management of chronic
pain.
Manchikanti et al. Pain Physician 2009;12: 699 (in press).

45. summary
 Chronic Pain is a very complex disease, not a symptom
 Progress is focused on targeting treatment at
the mechanisms that produce pain rather than ameliorating
the symptoms
 Biopsychosocial & multispeciality approach is critical for the
successful management of chronic Pain
 Current standards & future in chronic Pain treatment include
 Uses of new & multimodal agents
 Early Interventions to reduce incidence of chronic pain
 uses of Modern techniques
 Constant research for better understanding of brain imprint &
objectifying pain

46. Thank you