interventional approach to back pain management
TRANSCRIPT
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