interventional approach to back pain management

Dr (Maj) Pankaj N SurangeMBBS, MD (Anesthesiology), FIPP (Hungary)

Director, Interventional Pain and Spine Centre, New DelhiChairman, World Institute of Pain, India Chapter

Founder Member and Treasurer, MSK Ultrasound Society

Interventional Pain management

Interventions are Minimally Invasive, Non Surgical and Target Specific procedures to

Diagnose and to treat Various painful conditions

It fills the gap between pharmacologic management

of pain & more invasive operative procedure

• 36 Years, Executive

• Back pain with radiation to Left leg for 4 months.

• Lost his job.

• Progressively increasing and association with paraesthesia.

Case 1-Contained Disc Herniation

.

Management : Disc Herniation

Under fluoroscopic Guidance Correct level of the prolapsed disc is identified

Needle is inserted into the centre of the Disc and ozone is Injected.Pain relief starts usually within one week and ozone takes 3-4 weeks for its complete effect

Percutaneous Ozonucleolysis + Transforaminal L5 and S1

Minimally invasive procedure using small needle and probe to remove disc material of prolapsed disc ,releasing pressure on nerves and relieving pain

in most of the patients of prolapsed/ bulging / slipped disc

Management : Disc Herniation

Percutaneous disc decompression

Rotating tip removes small portion of disc

material. Because only enough of the disc is removed to reduce pressure inside

the disc, the spine remains stable.

Insertion site covered with bandage.

Recovery is fast as unlike surgical decompression no bone or muscle is cut.

2-3 days of bed rest and may return to normal activity within one week.

Management : Case 1

Percutaneous disc decompression

Nucleotomy

Hydrodiscectomy

Extruded disc

Radicular Pain

Transforaminal Selective nerve root block

Transforaminal Endoscopic Discectomy

• 42 Yrs/ Male• Back pain X 2 yrs• No h/o radiation to legs• Aggravating factors

• Sitting > 40 min• Driving• Forward bending

Case-2

Case 2- Discogenic Pain

Discogenic Pain

Risk Factors for degeneration of disc

Intradiscal Electrotherapy (IDET)

Biculoplasty

• Intradiscal Ozone

By inhibiting inflammatory nociceptors

Facet Arthropathy

• Low back pain- unilateral or bilateral

• Tenderness over facet joints• Pain is deep, dull aching,

difficult to localize• Referred to the buttocks,

groin, hip, or posterior and lateral thigh.

• Pain is more prominent in the morning and with inactivity

• May aggravate on extension after forward flexion

Facet Arthropathy secondary to Disc degeneration

• Disc bears 80% of weight• Facet joints bears 20 % of weight

A change in the intervertebral disc producesChange in the whole motion segment

Management- Facet Arthropathy

Inflammatory Type Degenerative type

Intra-articular Steroid

RF Ablation Median Branch

• 56 yrs /Female• Severe radicular pain in Rt Leg• H/o frequent back pains• Sensory loss in L5 Distribution and EHL- 4/5.• Known case of Rheumatoid Arthritis, Uncontrolled

DM, CAD, Interstitial Lung disease.

Case-3

Intraspinal Synovial Cyst

Management :Case 3• Percutaneous Transforaminal Cyst Aspiration

• 70 Yrs male/ obese• Back pain Rt > lt• Radiation to rt thigh --- lat surf of rt leg• Tossing on chair• 1st Investigation ordered –MRI LS SPINE

Case-4

MRI

Physical Examination

Rt SI Joint Tenderness +++

Management- Case 4S I Joint Injection

• 35 yrs/Female• Known case of CA Cervix• Metastasis• Sudden onset of severe pain mid back• No neurological deficit

Case-5

Compression Fracture Vertebral body

– 45 Yrs Male, only earning member – Traumatic Fracture D12 Vertebra– Totally bed ridden, Urinary catheter, Ryles tube feed

Case-7

Fracture D12 Vertebra

Osteoporotic Compression fracture

Vertebroplasty

Kyphoplasty

• 38 yrs male

• Low back pain radiating to both legs more on right side.

• He had history of disc prolapse of L4-5 & L5-S1 and has undergone surgery 2 times before (laminectomy, discectomy & excision of scar).

• Pain is increasing day by day.

• Repeated investigations & visit to 16 consultants for last 4 years has taken away all faith from any form of medical treatment.

• MRI-Epidural Fibrosis

Case-8

Failed Back Syndrome (FBSS)

• Epidural Adhenolysis

Resistant Case of FBSS

Interventional Pain Procedures

• Limitations

• Contraindications

• Complications

• Not Alternative to Surgery